Form 0920-0995 Basic Long Term Evaluation

National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC): Evaluation

OMB No. 0920-0995

Attachments 31 & 32

Basic Long-term Evaluation Instrument

Word version and screenshot

TODAY’S DATE

____________________________

M M D D Y Y

Your confidential ID number is the first two letters of your FIRST name, the first two letters of your LAST name, the MONTH of your birth, and the DAY of your birth.

FN	FN	LN	LN	M	M	D	D

CONFIDENTIAL IDENTIFIER

Basic Long-Term Evaluation

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0995).

A1f. I am using what I learned in this training in my work.

strongly disagree











Strongly agree

77

NA

A2f If you have not used what you learned, please explain why not.

A3f Did you make a change in your practice, worksite setting, or job as a result of this training?

 Yes

 No

 Not applicable to my job or patients

 I was already using these practices

 Other reason (please specify)

A4f If you made a change, what change did you make?

A5f As a result of this training, did you share what you learned with any of the following? (select all that apply)

 Supervisor

 Colleagues/co-workers

 Policy makers

 Community

 Other (please specify) _____________________________

UseGuidef Do you use the CDC STD Treatment Guidelines to guide the care of your patients/clients?

No, I am not aware of the Guidelines

I am aware of the Guidelines but do not use them

I use the Guidelines occasionally

I use the Guidelines consistently

I use another source to guide my STD care (please specify) ______________