Evaluation - Module 2: Team-Based Engagement Strategies

PLEASE NOTE: ALL CERTIFICATES WILL BE SENT ELECTRONICALLY. IF YOU WOULD LIKE TO RECEIVE A HARD-COPY OF YOUR CERTIFICATE, BE SURE TO PROVIDE YOUR COMPLETE MAILING ADDRESS IN THE APPROPRIATE QUESTIONS BELOW. ------------------------------------------------------------------------------- Learning Objectives: 1. Describe the key components of AHRQ's "Be Prepared to Be Engaged" tool. 2. Define patient activation. 3. Understand the ways in which "Be Prepared to Be Engaged" can be utilized in primary care.

1. Did the training meet all of the learning objectives listed above?*

Please utilize the 4 - 1 scale below: 4 - The learning objectives were fully met. 3 - The learning objectives were mostly met. 2 - The learning objectives were somewhat met. 1 - The learning objectives were not met.

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2. The scholarship and expertise of Emily Kane, MPA?*

Please utilize the 4 - 1 rating scale below to answer questions 2 & 3: 4 - Excellent 3 - Good 2 - Fair 1 - Poor

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3. The scholarship and expertise of Kelly Smith, PhD?

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4. Your overall satisfaction with the webinar/training?*

Please utilize the 4 - 1 rating scale below: 4 - Completely satisfied 3 - Mostly satisfied 2 - Somewhat satisfied 1 - Dissatisfied

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5. The webinar presented new ares of knowledge and/or new ideas/methods to implement?*

Please utilize the 4 -1 rating scale below: 4 - Completely agree 3 - Mostly agree 2 - Somewhat agree 1 - Disagree

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6. The webinar contained information at a level commensurate with my training and experience?*

Please utilize the 4 - 1 rating scale below: 4 - Completely agree 3 - Mostly agree 2 - Somewhat agree 1 - Disagree

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7. How helpful was the information you learned today in enhancing the performance and operations of your health center?*

Please utilize the 4 - 1 rating scale below: 4 - Completely helpful 3 - Mostly helpful 2 - Somewhat helpful 1 - Not helpful N/A - Not applicable

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8. If applicable, how do you plan to use the information you learned into your daily work?*

9. Was the content balanced and free of commercial bias?*

Key for questions 9 & 10: 1 - Yes 2 - No

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10. Did the speaker(s) fully disclose any conflict of interest and discussion of off-label usage of medications and/or medical devices?

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11. Do you have any training, technical assistance, or resource need? If so, please specify below.

12. What is the biggest challenge for your clinic in providing quality care to patients?

13. Name (as it should appear on your certificate)*

14. Credentials*

15. Certificate Type*

Please use the following key to select a certificate type that you would like to receive. NOTE: TEXAS CHW CERTIFICATES ARE NOT AVAILABLE FOR THIS TRAINING 1 - Continuing Medical Education (CME) 2 - Continuing Nursing Education (CNE) 3 - Texas CHW Certificate 4 - Certificate of Attendance

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16. Would you like to receive a hard-copy of your certificate?

KEY: 1 - Yes please 2 - No thanks

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17. Name of the organization you represent*

18. Organization Type*

Please utilize the key below to identify the type of organization you represent: 1 - PCA 2 - Health Center 3 - HCCN 4 - Self reported Other 5 - None of the above / I'm not sure

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19. What is your occupational title?*

20. Address*

21. City

22. State*

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23. Zip Code*

24. E-mail Address*

25. Phone Number

26. Type of number provided*

Please utilize the following key: 1 - Cell phone / Mobile phone 2 - Home phone 3 - Work phone

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