Form Approved
OMB No.0990-0379
Exp. Date 09/30/2023
OASH Office of Regional Health Operations
Thank you for participating in our webinar or meeting. Please take a moment to complete this brief, anonymous survey. If you feel the statement does not apply to you, please choose not applicable when rating the following statements. Your comments will help us improve our educational outreach efforts.
REQUIRED QUESTIONS
How much do you agree or disagree with the following statements?
The webinar/meeting increased my knowledge and understanding about [insert topic].
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
I intend to apply what I learned in my work.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
I am satisfied with the overall quality of the information presented during the webinar/meeting.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
I am satisfied with the logistical information (such as learning objectives, participation instructions, etc.) I received prior to the webinar/meeting.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
Please share suggestions for other topics or for improving future webinars/meetings.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, and gather the data needed to complete and to review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
OPTIONAL QUESTIONS
My understanding of the role of my agency/division/department in addressing the [insert topic] has increased.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
My understanding of prioritizing the needs of various populations [insert topic] has increased.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
I am able to identify at least one new promising practice relevant to addressing [insert topic].
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
I am able to identify at least one new resource that can help inform efforts to address [insert topic] in our community.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
I am able to identify next steps to advance efforts to [insert topic] in my [community/organization/or work].
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
I plan to follow-up and explore potential partnerships/collaborations with others that I met or heard from today.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
The [Name of Webinar or Meeting] has increased my practical skills regarding [Topic 1]. (Insert/delete as many topics as necessary)
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
As a result of the [information I learned, knowledge I gained] through the [Name of Webinar or Meeting], I will be more effective in my work.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
As a result of my involvement in the [Name of Webinar or Meeting], I have improved my connections with peers/colleagues.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
As a result of my participation, I am able to [Name of Webinar or Meeting – Goal 1]. (Insert/delete as many objectives/goals as necessary)
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
☐ Not Applicable
Which of the following best describes your organizational affiliation?
☐ State, local, territorial, or tribal government
☐ Local or county public agency/organization
☐ Federal government
☐ For profit private sector
☐ Non-profit sector (e.g. community-based organization, faith-based organization)
☐ Philanthropy or foundation
☐ Academia
☐ Other (Please describe)
OPTIONAL OPEN-ENDED QUESTIONS
What aspects of the [Name of Webinar or Meeting] will be most useful for your work?
Do you have any other comments or suggestions for the planning group?
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Form Approved |
| Author | DHHS |
| File Modified | 0000-00-00 |
| File Created | 2022-06-24 |