* Required Information
Date
*
Your gender
Male
Female
Your age
15-19
20-29
30-39
40-49
50-59
60+
Your ethnicity
African-American
American Indian
Asian/Pacific Islander
Hispanic/Latino
White/Caucasian
Other
Other
Overall, how would you rate this course?
Excellent
Good
Average
Poor
How useful was the Participant Journal in helping you meet your goals for the course?
Very useful
Useful
Not Useful
How useful were the out-of-session assignments in helping you meet your goals for the course?
Very useful
Useful
Not Useful
How useful was the Personal Change Plan in helping you meet your goals for the course?
Very useful
Useful
Not Useful
How useful were the class discussions in helping you meet your goals for the course?
Very useful
Useful
Not Useful
How useful were the small group activities in helping you meet your goals for the course?
Very useful
Useful
Not Useful
How would you rate your facilitator in the area of being prepared?
Excellent
Good
Average
Poor
How would you rate your facilitator in the area of making participants feel comfortable?
Excellent
Good
Average
Poor
How would you rate your facilitator in the area of involving everyone in discussion?
Excellent
Good
Average
Poor
How would you rate your facilitator in the area of explaining the material clearly?
Excellent
Good
Average
Poor
How would you rate your facilitator in terms of overall quality?
Excellent
Good
Average
Poor
How valuable was the course material in helping you change your behavior?
Very valuable
Valuable
Not at all valuable
How much did you learn from the course?
I learned a lot
I learned a little bit
I learned nothing
How useful do you think the course information will be to you in the future?
Very useful
Somewhat useful
Not at all useful
Have you or will you share your Participant Journal with anyone outside the class?
I have
I will
I will not
Will you keep your Participant Journal after the course ends?
Yes
No
Do you feel this course helped you make a change in your behavior?
Yes
No
The thing I liked best about this course is
The thing I liked least about this course is
How would you describe this course to a friend?