If you want to receive continuing education hours for completing this training, you must fill out and submit this evaluation form. Please include your name below so we can show that you met the requirement of filling out the form. If you do not want continuing education units we still, of course, want your feedback but you do not have to include your name.

Name:

E-mail: Phone:

Please select the approximate number of minutes it took you to complete the training: Less than 30 30 40 50 60 1 hour, 10 min. 1 hour, 20 min. 1 hour, 30 min. 1 hour, 40 min. 1 hour, 50 min. 2 hours 2 hours, 10 min. 2 hours, 20 min. 2 hours, 30 min. 2 hours, 40 min. 2 hours, 50 min. 3 hours More than 3 hours

1.  My overall evaluation of the training is:  

Excellent    Good    Fair    Poor

2. By the end of the training, do you feel you could -          

A. Recognize potential environmental hazards and illnesses as part of a primary prevention approach?             

                    Yes   No

B. Complete a pediatric environmental health history?                 

                    Yes   No

C. Recommend a course of preventative action or make appropriate referrals for conditions?

                    Yes   No

3. Circle "yes" or "no" for the following items:

A. Did the training meet your expectations?               

                    Yes    No                                         

B. Would you recommend this training to a colleague?

                    Yes    No                           

C. Was the content of this training relevant to your job?

                    Yes    No 

4. To what extent did the training meet its learning objectives?

                    Completely    Much of it    Only some    Not at all

5. Can you incorporate concepts learned during the course into your daily work right away?

                    Yes    Much of it    Only some    Not at all

        5a. If not at all, why not?

6. Overall quality of training format:

    A. Relation of material to problems and issues in my practice

        Excellent    Average    Poor

    B. Scenario for home visit

        Excellent    Average    Poor

    C. Survey Form

        Excellent    Average    Poor

    D. Nursing Care Plan form

        Excellent    Average    Poor

    E. Additional comments:

7. For each of the following problems, please check any of the following actions that you feel confident you would be able to do on a home visit. (Check all that apply)

8. Do you plan to use the Pediatric Environmental Home Assessment Survey form or Nursing Care Plan form on home visits?

                Yes        Yes, but will make changes    No

If no, why not?

8a. Would the Survey Form or Nursing Care Plan form be more useful to you if  medical information items such as asthma management were added?

                Yes          No

9. Are you interested in additional training on healthy homes? If yes, please check the courses below that you are interested in taking. If you have ideas for other courses, please click Other and write a short description.

                Yes          No

Essentials for Healthy Homes Practitioners (if you have not already taken it)

Essentials for Healthy Homes Practitioners in Spanish

Integrated Pest Management in the Indoor Environment: Principles and Practice

IPM in Multi-Family Housing

Healthy Homes for Community-Based Organizations

Launching a Healthy Homes Initiative

Lead-Safe & Healthy Homes Work Practices

Healthy Homes for Health Promoters

Other