Facilitator Evaluation for Prescription Opioid Toolkit
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Montana State University Extension
Prescription Opioid Education & Awareness Toolkit - Facilitator Evaluation
Program Location: _________________________________________________________________________________________
Date(s) & Time(s): _________________________________________________________________________________________
Your input and feedback are valuable to our education efforts. By completing this evaluation form, you are providing us with the necessary information to more effectively educate the public about opioids and the potential hazards associated with opioids. Thank you!
Audience Characteristics
Age:
Age group |
Number of participants |
Under 18 |
|
18 – 24 |
|
25 – 34 |
|
35 - 44 |
|
45 - 54 |
|
55 - 64 |
|
65+ |
|
Gender:
Gender |
Number of participants |
Female/Woman |
|
Male/Man |
|
Trans Male/Trans Man |
|
Trans Female/Trans Woman |
|
Gender Queer/Nonbinary |
|
Another identity not listed above |
|
Race/Ethnicity:
Race |
Number of participants |
Hispanic or Latino |
|
American Indian or Alaskan Native |
|
Asian |
|
Black or African American |
|
Native Hawaiian or other Pacific Islander |
|
White |
|
Implementation Details and Feedback
Reason(s) for conducting this program (requested by a group/organization, open to the public): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Toolkit usage - please indicate the toolkit modules utilized:
- Module 1: Introduction to Opioids
- Module 2: Prescription Opioids & Home Safety: Proper Storage & Disposal
- Module 3: Stigma & Opioid Use Disorder
- Module 4: Prescription Opioid Use Disorder: Community Resources
- Bonus Module: Opioid Use Disorder Treatment & Recovery Information
Ease of implementation – please rate whether or not the module(s) were “user-friendly”:
- Extremely difficult
- Somewhat difficult
- Neutral
- Somewhat “user-friendly”
- Extremely “user-friendly”
Estimated time for completion:
- Significantly underestimated (took far more time than anticipated)
- About right (time to complete session(s) was accurately anticipated)
- Significantly overestimated (took far less time than anticipated)
List any challenges or concerns associated with the implementation of these lessons:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Perception of audience reactions to the lesson(s):
- Very negative
- Negative
- Neutral (or mixed)
- Positive
- Very positive
Perception of audience interest/engagement:
- Extremely disinterested/disengaged
- Disinterested/disengaged
- Neutral (or mixed)
- Interested/engaged
- Extremely interested/engaged
Please list any challenges or concerns regarding audience reactions, questions/comments, or engagement: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Were there any portions of the module(s) that you omitted or modified? If so, please describe these changes and why you made them.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Did you present the lesson(s) yourself or did you use the pre-recorded slideshow(s)?
- Presented myself
- Used pre-recorded slideshow
Please indicate which of the following materials you utilized during your session(s). If you distributed any of these materials, please indicate that as well:
|
Utilized |
Distributed |
|
Module 1 |
|
|
|
• |
Common Names for Prescription Opioid Pain Medications |
□ |
□ |
• |
2021 CDC Drug Overdose Deaths, 2015-2020 |
□ |
□ |
• |
MontGuide: Prescription Opioid Use and Misuse in Montana |
□ |
□ |
Module 2 |
|
|
|
• |
DPHHS – Addictive & Mental Disorders Division, Mental Health Services Bureau Programs & Contacts |
□ |
□ |
• |
Montana Standing Order for Naloxone Opioid Antagonists, Jan. 1, 2021 |
□ |
□ |
• |
Montana Implementation Guide for Access to Naloxone Opioid Antagonists, May 2019 |
□ |
□ |
• |
Montana Prescription Drug Drop Box Locations |
□ |
□ |
• |
Permanent Prescription Drug Drop Box Locations in Montana |
□ |
□ |
• |
Drug Disposal: FDA’s Flush List for Certain Medications |
□ |
□ |
• |
Prescription Drugs/Medications: Proper Use, Storage & Disposal |
□ |
□ |
• |
Website Links for the Proper Disposal of Prescription Medications |
□ |
□ |
Module 3 |
|
|
|
• |
MontGuide: Stigma Free Addictions Terminology for Montanans |
□ |
□ |
Module 4 |
|
|
|
• |
DPHHS – Addictive & Mental Disorders Division, Mental Health Services Bureau Programs & Contacts |
□ |
□ |
• |
Montana Standing Order for Naloxone Opioid Antagonists, Jan. 1, 2021 |
□ |
□ |
• |
Montana Mental Health Centers Directory |
□ |
□ |
• |
Montana Implementation Guide for Access to Naloxone Opioid Antagonists, May 2019 |
□ |
□ |
• |
Website Links for Community Resources |
□ |
□ |
• |
2021 CDC Drug Overdose Deaths, 2015-2020 |
□ |
□ |
• |
MontGuide: Understanding and Finding Mental Health Providers |
□ |
□ |
Bonus Module |
|
|
|
• |
2021 CDC Drug Overdose Deaths, 2015-2020 |
□ |
□ |
Additional Toolkit/Module Feedback:
Use the space below to provide additional feedback and/or suggestions to improve this
module or toolkit.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thank you for completing this evaluation form. Submit this form to Jennifer Munter, Program Manager by email (jennifermunter@montana.edu) or by mailing to: P.O. Box 173370, Bozeman, MT 59717-3370 (Attn: Jennifer Munter).
For more information about the MSU Extension Opioid Awareness & Education Program visit: http://health.msuextension.org/opioid_misuse.html or contact Barbara Allen, Project Director at: blallen@montana.edu.