2019 BSI QIA: Webinar Attestation Survey

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* 1. Select your facility from the drop down list.

If your facility is not listed above, enter your CCN and FULL FACILITY NAME.

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* 2. Complete the below information.

First name of the person completing this survey.

Last name of the person completing this survey.

Email address of the person completing this survey.

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* 3. Please list the Primary and Secondary Contacts for this project. (If unknown, list the Facility Administrator for the Project Lead and Backup)

Project Lead: First Name

Project Lead: Last Name

Project Lead: Email

Project Lead: Title

Project Backup: First Name

Project Backup: Last Name

Project Backup: Email

Project Backup: Title

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* 4. What date did you attend the webinar?

Tuesday January 22, 2019

Wednesday January 23, 2019

If you did not attend the webinar and watched the recording instead, please enter date below (MM/DD/YYYY)

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* 5. Complete the following polling questions.

	Strongly Agree	Agree	Disagree	Strongly Disagree
This webinar met its stated objectives.	This webinar met its stated objectives. Strongly Agree	This webinar met its stated objectives. Agree	This webinar met its stated objectives. Disagree	This webinar met its stated objectives. Strongly Disagree
This webinar gave me clear instructions on how to implement and report the 4 CDC audits.	This webinar gave me clear instructions on how to implement and report the 4 CDC audits. Strongly Agree	This webinar gave me clear instructions on how to implement and report the 4 CDC audits. Agree	This webinar gave me clear instructions on how to implement and report the 4 CDC audits. Disagree	This webinar gave me clear instructions on how to implement and report the 4 CDC audits. Strongly Disagree
This webinar gave me clear instructions on how to complete the Patient Engagement Activities.	This webinar gave me clear instructions on how to complete the Patient Engagement Activities. Strongly Agree	This webinar gave me clear instructions on how to complete the Patient Engagement Activities. Agree	This webinar gave me clear instructions on how to complete the Patient Engagement Activities. Disagree	This webinar gave me clear instructions on how to complete the Patient Engagement Activities. Strongly Disagree
I fully understand the project requirements.	I fully understand the project requirements. Strongly Agree	I fully understand the project requirements. Agree	I fully understand the project requirements. Disagree	I fully understand the project requirements. Strongly Disagree
I know the location of the reviewed materials, and I know where to find additional resources if I need them.	I know the location of the reviewed materials, and I know where to find additional resources if I need them. Strongly Agree	I know the location of the reviewed materials, and I know where to find additional resources if I need them. Agree	I know the location of the reviewed materials, and I know where to find additional resources if I need them. Disagree	I know the location of the reviewed materials, and I know where to find additional resources if I need them. Strongly Disagree
I know who to contact from the Network if I need assistance.	I know who to contact from the Network if I need assistance. Strongly Agree	I know who to contact from the Network if I need assistance. Agree	I know who to contact from the Network if I need assistance. Disagree	I know who to contact from the Network if I need assistance. Strongly Disagree
This webinar was held at a convenient time	This webinar was held at a convenient time Strongly Agree	This webinar was held at a convenient time Agree	This webinar was held at a convenient time Disagree	This webinar was held at a convenient time Strongly Disagree

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* 1. Select your facility from the drop down list.

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* 2. Complete the below information.

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* 3. Please list the Primary and Secondary Contacts for this project. (If unknown, list the Facility Administrator for the Project Lead and Backup)

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* 4. What date did you attend the webinar?

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* 5. Complete the following polling questions.

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* 6. Any comments or feedback to improve this project or webinar.