Facilitator Evaluation for Parental Awareness and Action Training Module
Montana State University Extension
Prescription Opioid and Stimulant Education & Awareness Parental Awareness and Action Training Module - 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 stimulants and the potential hazards associated with these medications. 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): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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 training module that you omitted or modified? If so, please describe these changes and why you made them.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Did you present this module yourself or did you use the pre-recorded slideshow?
- 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:
HANDOUTS:
Talking With Adolescents About Opioid and Stimulant Misuse
-
- Utilized (yes/no)__________
- # Distributed___________
DEA Counterfeit Pills Fact Sheet (Dec 2021)
- Utilized (yes/no)__________
- # Distributed___________
Emoji Drug Code: Decoded Handout
- Utilized (yes/no)__________
- # Distributed___________
Prescription Opioid and Stimulant Misuse Among Youth Fact Sheet
- Utilized (yes/no)__________
- # Distributed___________
Be Aware of These Common Stimulants Infographic
- Utilized (yes/no)__________
- # Distributed___________
VIDEOS:
Opioid Misuse: A Montanan Discusses the Four Phases of His Recovery From Opioids
- Utilized (yes/no)__________
Insight Into the Teenage Brain Video (UCLA researcher and assistant professor Dr. Adriana Galvan)
- Utilized (yes/no)__________
Taking Prescription Opioids Safely
- Utilized (yes/no)__________
Taking Prescription Stimulants Safely
- Utilized (yes/no)__________
OTHER RESOURCES:
Help Save Lives Act: Montana Annotated Code 2021
- Utilized (yes/no)__________
Module 1: Introduction to Opioids (derived from the Prescription Opioid Awareness and Education Toolkit)
- Utilized (yes/no)__________
Additional 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.