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DHPD - Improving the Oral Health of Pregnant Women, Children & Families Evaluation
1.
Today's Date:
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2.
Which type(s) of certificate would you like?
CHW/CHR Certificate (5.75 Units from the New Mexico Department of Health)
Continuing Medical Education Certificate for Physicians (6.25 Units)
Continuing Medical Education Certificate for Non-Physicians (6.25 Units)
Not Applicable (not requesting CEUs or CMEs)
3.
Please provide your name and email address if you are requesting CEUs or CMEs.
Name
Email Address
4.
What is your role?
Community Health Worker (CHW)
Community Health Representative (CHR)
Other (please specify)
5.
Which county do you serve? (If multiple, choose primary county)
Bernalillo
Catron
Chaves
Cibola
Colfax
Curry
De Baca
Dona Ana
Eddy
Grant
Guadalupe
Harding
Hidalgo
Lea
Lincoln
Los Alamos
Luna
McKinley
Mora
Otero
Quay
Rio Arriba
Roosevelt
Sandoval
San Juan
San Miguel
Santa Fe
Sierra
Socorro
Taos
Torrance
Union
Valencia
6.
Training Objectives and Content
Strongly Agree
Agree
Disagree
Strongly Disagree
The objectives of this session were clearly explained
Strongly Agree
Agree
Disagree
Strongly Disagree
Overall the session met its objectives
Strongly Agree
Agree
Disagree
Strongly Disagree
7.
Because I attended this training:
Strongly Agree
Agree
Disagree
Strongly Disagree
I have gained valuable knowledge and skills
Strongly Agree
Agree
Disagree
Strongly Disagree
There will be a positive impact on my
professional work
Strongly Agree
Agree
Disagree
Strongly Disagree
8.
Overall, I am satisfied with the training.
Strongly Agree
Agree
Disagree
Strongly Disagree
Strongly Agree
Agree
Disagree
Strongly Disagree
9.
Do you feel this presentation conveyed any commercial bias?
No
Yes
10.
Can you think of changes you might make to your professional practice as a result of this training?
11.
What do you think some of the barriers will be to making changes in your practice?
