Primary Care HCV Treatment Training Program Evaluation

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* 1. Name

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* 2. Contact Information

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. Age

Under 18

18-29

30-49

50-64

65+

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* 4. Gender

Male

Female

Other

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* 5. Race/Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 6. If you are a medical provider, please specify the field:

MD/DO

RN/LPN

PharmD

Other (please specify)

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* 7. What is your speacialty?

Primary Care

Other (please specify)

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* 8. How did you hear about this program?

Program Brochure

Doctor/Hospital

Dept. of Health/CBO

Other (please specify)

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* 9. Have you been to a CLA program before?

Yes

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* 10. Rate the following:

	Excellent	Good	Fair	Poor
Materials and handouts	Materials and handouts Excellent	Materials and handouts Good	Materials and handouts Fair	Materials and handouts Poor
Audio/visual aids	Audio/visual aids Excellent	Audio/visual aids Good	Audio/visual aids Fair	Audio/visual aids Poor
Location	Location Excellent	Location Good	Location Fair	Location Poor
Overall program information	Overall program information Excellent	Overall program information Good	Overall program information Fair	Overall program information Poor
Overall program organization	Overall program organization Excellent	Overall program organization Good	Overall program organization Fair	Overall program organization Poor
Speaker(s)	Speaker(s) Excellent	Speaker(s) Good	Speaker(s) Fair	Speaker(s) Poor

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* 11. What else would you like to learn? Any suggested topics for future trainings?

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* 12. Other Comments:

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* 13. Would you like to receive more information about liver wellness and liver disease?

Yes

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* 14. Would you like to volunteer for your local CLA?

Yes

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* 15. Will you be an advocate for the CLA?

Yes