Form 1 Ryan White 2018 Session Evaluation 9.18.2018 FINAL2

Program evaluation for Sample Evaluation Form
Please fill in the following form to help us improve our educational activities.
Public Burden Statement: 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. The OMB control number for this project is 0915-0212. Public
reporting burden for this collection of information is estimated to av-erage 0.05 hours per response, including the time for
reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of in-formation, including suggestions for reducing
this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.
Please rate the following aspects of this educational activity on a descending scale where 5 = excellent to 1 = poor.

Rating

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Overall quality of the educational activity:
Teaching strategy employed:
Relevance of the educational activity to your work:
Quality of the materials used in the activity:
Helpfulness of the information presented:
Contributed to my knowledge, skills, and abilities to enhance the delivery of client care:
The intended result of this activity is improvement in competence, performance, and client care. Please rate the effectiveness of this
activity to fulfill these learning outcomes and achieve the intended result on a descending scale where 5 = excellent to 1 = poor.
Learning Outcome

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EXAMPLE OUTCOME 1
EXAMPLE OUTCOME 2
EXAMPLE OUTCOME 3
Please rate presenters for this educational activity using a descending scale where 5 = excellent to 1 = poor.

EXAMPLE SPEAKER 1

Evaluation Area
Presentation Style:
Organization and Clarity:
Expertise:
Relevance to Outcomes:

EXAMPLE SPEAKER 2

Evaluation Area
Presentation Style:
Organization and Clarity:
Expertise:
Relevance to Outcomes:

Evaluation Area

EXAMPLE SPEAKER 3

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Presentation Style:
Organization and Clarity:
Expertise:
Relevance to Outcomes:
Please answer the following questions as they relate to the educational activity.
Based on your previous knowledge and experience, the level of
this activity was:

Do you feel that the activity was objective, balanced, and free of
commercial bias?

 Too basic
 Appropriate
 Too complex
 Yes
 No

If no, why not?
Enter optional response in this area

Was disclosure (financial relationships, unapproved or
unlabeled use of drugs or products) made available to you
during the activity?

 Yes
 No

Was the activity supported by scientifically-rigorous or
evidence-based data?

 Yes
 No

Did the activity meet your educational needs?

 Yes
 No

If no, why not?
Enter optional response in this area

Please rate how much you agree that this educational activity has contributed to your professional effectiveness and ability to execute the following, using a descending scale where 5 = strongly agree to 1 = strongly disagree:
Improvement Area
Treat and/or manage my clients:
Communicate with clients:
Manage my clinical practice and/or program:

After completing this activity, do you anticipate changing any of
your client care practices and/or program?

 Yes
 No

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If you answer yes, what do you anticipate changing or how will you integrate what you learned into practice?
Enter optional response in this area

Do you see any barriers to implementing these changes?

 Yes
 No

If you answer yes, please rate these barriers using a descending scale where 5 = major barrier to 1 = little or no barrier:
Barrier
Organization:
Current policy/procedure:
Technology:
Financial:
Clinical research:
Other: (please list)  Enter “other” response here

Comments or suggestions for improvement:
Enter optional response in this area

OMB Number: 0915-0212. Expiration date: 07/31/2021

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