Evaluation - Module 5: Patient Self-Management and Goal Setting

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. Participants will discuss ways in which motivational interviewing skills can be used to help patients construct realistic self-management goals. 2. Participants will engage in role-playing to employ goal setting skills to real life patient situations. 3. Participants will summarize motivational interviewing and goal setting strategies that will be applicable to their own patient population.

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

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

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2. The scholarship and expertise of Sarah Solis, LCSW?*

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

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3. Your overall satisfaction with the webinar training?*

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

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

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

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

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

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

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

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

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

Please utilize the key below: 1 - Yes 2 - No

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

Please utilize the key below: 1 - Yes 2 - No

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10. Do you have any training, technical assistance or resource needs? If so, please specify below.*

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

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

13. What type of organization do yo represent?*

Key: 1 - PCA 2 - Health Center 3 - HCCN 4 - Government (state/federal) 5 - Self reported other 6 - None of the above / I'm not sure

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14. Please identify the type of certificate you would like to receive for this training.*

Key: 1 - Continuing Medical Education (CME) 2 - Continuing Nursing Education (CNE) 3 - Texas CHW Certificate 4 - Certificate of Attendance

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

Key: 1 - Yes please 2 - No thanks

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16. Address*

17. City*

18. State*

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19. Zip Code*

20. Email Address*

21. Phone Number*

Please provide your phone number in the following format: xxx - xxx - xxxx

22. Type of number provided*

Key: 1 - Cell / Mobile 2 - Home / Residence 3 - Work / Business

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