It's Your Right to Know! Helping Community Health Workers Promote Chemical Safety on the Job

Learning Objectives:

1. Recognize how workers are exposed to chemicals on the job and the health effects. 2. Describe basic safety practices when working around chemicals. 3. Understand the role of Community Health Workers in helping workers prevent chemical exposure.

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

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 completely met.

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2. The scholarship and expertise of Amy Liebman, MPA, MA?*

1 - Poor 2 - Slight 3 - Moderate 4 - Excellent

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3. Your overall satisfaction with this webinar training?*

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.*

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.*

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 improving the performance and operations of your health center or organizaiton?*

N/A - Not applicable 1 - Not at all helpful 2 - Somewhat helpful 3 - Mostly helpful 4 - Completely helpful

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7. How important is it for you to integrate occupational and environmental health into community-oriented programs?*

1 - Not at all important 2 - Somewhat important 3 - For the most part important 4 - Completely important

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8. Please mention something that you learned in today's training and how you can implement what you learned into your job.*

If this does not apply to you, please enter "N/A" in the box below.

11. Do you or your organization have any specific need for training or technical assistance?

12. What is the biggest challenge faced by your health center or organization in serving patients, workers, or community members?

13. Additional Comments?

CERTIFICATES FOR THIS TRAINING WILL BE SENT ELECTRONICALLY. IF YOU WISH TO RECEIVE A HARD-COPY OF YOUR CERTIFICATE, PLEASE MAKE SURE TO FILL IN ALL APPROPRIATE FIELDS BELOW.

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

15. Please identify the type of organization you represent.

1 - PCA 2 - Community Organizaiton 3 - Health Center 4 - HCCN (Health Center Controlled Network) 5 - State agency 6 - Federal agency 7 - Other / Not included in this list 8 - I'm not sure / Don't know

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16. Please identify the type of certificate you would like to receive.

NOTE: ONLY CERTIFICATES OF ATTENDANCE WILL BE ISSUED FOR PARTICIPATING IN THIS TRAINING. 1 - Continuing Medical Education (CME) 2 - Continuing Nursing Education (CNE) 3 - Texas CHW Certificate 4 - Certificate of Attendance

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17. Address

18. City

19. State

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20. Zip Code

21. Email Address

22. Phone Number

Please enter your phone number in one of the following formats: xxx - xxx - xxxx OR (xxx) xxx - xxxx

23. Please indicate the type of phone number you provided.

1 - Cell/ Mobile 2 - Home 3 - Work/Office

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