Spike 2013 Reporting Form

1. Spike Reporting Form

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* 1. Name

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* 2. Email address

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* 3. School/Organization

Other (please specify)

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* 4. City/Town

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* 5. State

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* 6. Number of participating students

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* 7. Grade/Level (Check all that apply.)

Pre-K

Other (please specify)

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* 8. How much time did you time did you spend on poison prevention?

30 minutes or less

Between 30 minutes and an hour

More than an hour

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* 9. How user friendly did you find the program?

Very

Somewhat

Not sure

Not very

Not at all

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* 10. If the Spike Education Program was not available, would you teach poison prevention?

Yes

What program or materials would you use?

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* 11. What activities/materials did you use? (Check all that apply.)

Video

Student take-home packets

Sing Along With Spike (Teacher's Guide Activity)

Experience Chart (Teacher's Guide Activity, available on our website)

Can Good Things Be Bad for You? (Teacher's Guide Activity)

Candy or Medicine poster

Connect-the-dots activity page

Word search activity page

Do-it-yourself hand puppets

Home hunt (homework)

Pick the poison (homework)

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* 1. Name

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* 2. Email address

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* 3. School/Organization

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* 4. City/Town

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* 5. State

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* 6. Number of participating students

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* 7. Grade/Level (Check all that apply.)

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* 8. How much time did you time did you spend on poison prevention?

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* 9. How user friendly did you find the program?

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* 10. If the Spike Education Program was not available, would you teach poison prevention?

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* 11. What activities/materials did you use? (Check all that apply.)

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* 12. Please share any comments on the program or ideas for improving it.