Rx for Change - Tobacco Cessation Training Program Feedback Survey

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* 3. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Master's degree

Doctoral/PhD

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* 4. What is your ethnicity? (Please select all that apply.)

American Indian or Alaskan Native

Asian or Pacific Islander

Black or African American

Hispanic or Latino

White / Caucasian

Prefer not to answer

Other (please specify)

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* 5. Please indicate your rank? (For non-PHS Officers, please select "Other" and indicate branch or civilian)

ESN

LTJG

LCDR

CDR

CAPT

RADM

VADM

Other (please specify)

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* 6. Please select your category. (For non-PHS Officers, please select "Other" and state your profession)

Dentist

Dietitian

Engineer

Environmental Health Officer

Health Service Officer

Nurse

Medical

Pharmacist

Scientist

Therapist

Veterinarian

Other (please specify)

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* 7. Please select your agency.

AHRQ

ATSDR

BOP

CDC

DOD

FDA

HRSA

ICE

IHS

NIH

OASH

ASPR

SAMHSA

Other (please specify employer)

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* 8. In what state or U.S territory do you live?

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* 9. How was this presentation delivered to you?

Live

Online

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* 10. Date of training.

Please record date below:

Date

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* 11. Which program/event did you participate in? (If during a conference/webinar, select "Other" and indicate conference/webinar name or association)

Ambassador Program

Bureau of Prisons (BOP) Initiative

Food & Drug Administration (FDA) Initiative

None, completed independently

Other (please specify)

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* 12. Please rate the following:

	Poor	Fair	Average	Very Good	Excellent
Level of knowledge concerning tobacco cessation interventions PRIOR to this program	Level of knowledge concerning tobacco cessation interventions PRIOR to this program Poor	Level of knowledge concerning tobacco cessation interventions PRIOR to this program Fair	Level of knowledge concerning tobacco cessation interventions PRIOR to this program Average	Level of knowledge concerning tobacco cessation interventions PRIOR to this program Very Good	Level of knowledge concerning tobacco cessation interventions PRIOR to this program Excellent
Level of knowledge concerning tobacco cessation interventions AFTER this program	Level of knowledge concerning tobacco cessation interventions AFTER this program Poor	Level of knowledge concerning tobacco cessation interventions AFTER this program Fair	Level of knowledge concerning tobacco cessation interventions AFTER this program Average	Level of knowledge concerning tobacco cessation interventions AFTER this program Very Good	Level of knowledge concerning tobacco cessation interventions AFTER this program Excellent
Learning objectives were stated and clear	Learning objectives were stated and clear Poor	Learning objectives were stated and clear Fair	Learning objectives were stated and clear Average	Learning objectives were stated and clear Very Good	Learning objectives were stated and clear Excellent
Stated learning objectives were met with the materials provided within the module	Stated learning objectives were met with the materials provided within the module Poor	Stated learning objectives were met with the materials provided within the module Fair	Stated learning objectives were met with the materials provided within the module Average	Stated learning objectives were met with the materials provided within the module Very Good	Stated learning objectives were met with the materials provided within the module Excellent
Program materials were accurate and up to date	Program materials were accurate and up to date Poor	Program materials were accurate and up to date Fair	Program materials were accurate and up to date Average	Program materials were accurate and up to date Very Good	Program materials were accurate and up to date Excellent
Appropriate time was allotted to complete this program	Appropriate time was allotted to complete this program Poor	Appropriate time was allotted to complete this program Fair	Appropriate time was allotted to complete this program Average	Appropriate time was allotted to complete this program Very Good	Appropriate time was allotted to complete this program Excellent
If applicable, evaluator provided timely response in scheduling skills demonstration	If applicable, evaluator provided timely response in scheduling skills demonstration Poor	If applicable, evaluator provided timely response in scheduling skills demonstration Fair	If applicable, evaluator provided timely response in scheduling skills demonstration Average	If applicable, evaluator provided timely response in scheduling skills demonstration Very Good	If applicable, evaluator provided timely response in scheduling skills demonstration Excellent
If applicable, instructor was knowledgeable and effective at teaching program	If applicable, instructor was knowledgeable and effective at teaching program Poor	If applicable, instructor was knowledgeable and effective at teaching program Fair	If applicable, instructor was knowledgeable and effective at teaching program Average	If applicable, instructor was knowledgeable and effective at teaching program Very Good	If applicable, instructor was knowledgeable and effective at teaching program Excellent
Materials (Audiovisual, Powerpoint, handouts) were effective in covering the subject matter	Materials (Audiovisual, Powerpoint, handouts) were effective in covering the subject matter Poor	Materials (Audiovisual, Powerpoint, handouts) were effective in covering the subject matter Fair	Materials (Audiovisual, Powerpoint, handouts) were effective in covering the subject matter Average	Materials (Audiovisual, Powerpoint, handouts) were effective in covering the subject matter Very Good	Materials (Audiovisual, Powerpoint, handouts) were effective in covering the subject matter Excellent
How well this training program met your learning needs	How well this training program met your learning needs Poor	How well this training program met your learning needs Fair	How well this training program met your learning needs Average	How well this training program met your learning needs Very Good	How well this training program met your learning needs Excellent
Directions for program completion were clear and easy to follow	Directions for program completion were clear and easy to follow Poor	Directions for program completion were clear and easy to follow Fair	Directions for program completion were clear and easy to follow Average	Directions for program completion were clear and easy to follow Very Good	Directions for program completion were clear and easy to follow Excellent

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* 13. How likely are you to use the information used in this training program in your personal or clinical setting/practice?

Very Likely

Somewhat Likely

Somewhat Unlikely

Unlikely

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* 14. Was this program free of any bias or commercialism toward any particular product or company?

Yes

If No, please describe:

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* 15. How likely is it that you would recommend this program to a friend or colleague?

Not at all likely

Extremely likely

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* 16. Which of the following best describes you?

I am a "provider" in an established Tobacco Cessation Clinic at my facility

There is no Tobacco Cessation Clinic at my facility, but I counsel patients at every patient encounter (clinic visit, medication pick up, etc.)

I frequently deliver presentations regarding tobacco use and cessation to increase public awareness

I am a member of a national or community organization and participate in/host events regarding public health including tobacco use and cessation

As a public servant, I talk to family, friends and people I may encounter (that I know smoke or use tobacco) about tobacco cessation

Other (please specify)

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* 17. We would like to gauge the use of your skills obtained through this program on an annual basis. If you would like to participate in a brief annual survey, please provide your email address.

Rx for Change - Tobacco Cessation Training Program Feedback Survey

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* 1. Please indicate your gender.

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* 2. Age

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* 3. What is the highest level of school you have completed or the highest degree you have received?

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* 4. What is your ethnicity? (Please select all that apply.)

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* 5. Please indicate your rank? (For non-PHS Officers, please select "Other" and indicate branch or civilian)

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* 6. Please select your category. (For non-PHS Officers, please select "Other" and state your profession)

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* 7. Please select your agency.

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* 8. In what state or U.S territory do you live?

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* 9. How was this presentation delivered to you?

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* 10. Date of training.

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* 11. Which program/event did you participate in? (If during a conference/webinar, select "Other" and indicate conference/webinar name or association)

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* 12. Please rate the following:

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* 13. How likely are you to use the information used in this training program in your personal or clinical setting/practice?

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* 14. Was this program free of any bias or commercialism toward any particular product or company?

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* 15. How likely is it that you would recommend this program to a friend or colleague?

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* 16. Which of the following best describes you?

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* 17. We would like to gauge the use of your skills obtained through this program on an annual basis. If you would like to participate in a brief annual survey, please provide your email address.

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* 18. Please provide any additional comments, feedback, suggestions.