PORTFOLIO CONTENT

SAMPLE EVALUATION FORM

Training Center

TUBERCULOSIS INTENSIVE
<Date>

San Francisco, CA

SAMPLE EVALUATION FORM

1.What is your principal occupation? (circleonly one)

a.Physician

b.Nurse practitioner

c.Registered nurse

d.Public health nurse

e.Other:

(please specify)

2.Which of the following most closely describes your work setting?

(circle only one)

Public Private

a.TB clinic or practice

b.Public health or infectious disease clinic

c.Primary care, general medicine or family practice setting

d.Agency or program office:______

(specify health field)

e.Correctional facility

f.Other:

(please specify)

3.What percent of your job is devoted to TB? %

KEY:5 = excellent, 4 = good, 3 = average, 2 = fair, 1 = poor

DAY 1:

<Date>

excellent  poor

1. Epidemiology / delivery / 5 / 4 / 3 / 2 / 1
content / 5 / 4 / 3 / 2 / 1
syllabus / 5 / 4 / 3 / 2 / 1
FACULTY / usefulness / 5 / 4 / 3 / 2 / 1

Did the instructor meet the objective for this session?

By the end of this session, participants should be able to describe:

  • current epidemiology of tuberculosis in the United States YES ( ) NO ( )

Comments:

excellent  poor

2. Principles of tuberculosis control / delivery / 5 / 4 / 3 / 2 / 1
content / 5 / 4 / 3 / 2 / 1
syllabus / 5 / 4 / 3 / 2 / 1
FACULTY / usefulness / 5 / 4 / 3 / 2 / 1

Did the instructor meet the objective for this session?

By the end of this session, participants should be able to describe:

  • transmission and pathogenesis of M. tuberculosisand the impact of HIV infection

YES ( ) NO ( )

Comments:

EVALUATION OF COURSE PRACTICUM

GROUP:ABC(circle one)

KEY: 5 = excellent, 4 = good, 3 = average, 2 = fair, 1 = poor

excellent  poor

1.Public health laboratory tour / clarity of presentation / 5 / 4 / 3 / 2 / 1
content / 5 / 4 / 3 / 2 / 1
handouts / 5 / 4 / 3 / 2 / 1
FACULTY / usefulness / 5 / 4 / 3 / 2 / 1

Comments:

excellent  poor

2. TB clinic overview / clarity of presentation / 5 / 4 / 3 / 2 / 1
content / 5 / 4 / 3 / 2 / 1
handouts / 5 / 4 / 3 / 2 / 1
FACULTY / usefulness / 5 / 4 / 3 / 2 / 1

Comments:

excellent  poor

3.PPD screening / clarity of presentation / 5 / 4 / 3 / 2 / 1
content / 5 / 4 / 3 / 2 / 1
handouts / 5 / 4 / 3 / 2 / 1
FACULTY / usefulness / 5 / 4 / 3 / 2 / 1

Comments:

GENERAL COMMENTS

1.Overall, how would you rate this course? (circle one)

not useful fairly useful extremely useful

------

012345678910

2.The training manual was prepared specifically for this course. We would appreciate your feedback on the materials provided for this course. Please rate the following:

excellent  poor

content of material54321

not

appropriate appropriate

length of syllabus54321

excellent poor

usefulness of syllabus54321

easilydifficult to

understoodunderstand

comprehension of syllabus54321

3.Do you feel that the time allotted to each subject was appropriate?

If not, please specify below with a :

time was
appropriate / decrease
time / allow more time
Epidemiology
Transmission and pathogenesis
Principles of tuberculosis control
Clinical presentation and diagnosis
Treatment
Tuberculosis screening
Treatment of latent tuberculosis infection
Case studies
Legal and ethical issues in tuberculosis
Laboratory methods and preparation
Engineering for control of tuberculosis
Pediatric tuberculosis
Working lunch: pediatrics
Multidrug-resistant tuberculosis
Working lunch: case discussions
Radiology
Practicum:
Public health laboratory tour
TB clinic overview
PPD screening
DOT case study
Case discussions
Laboratory tour at San Francisco General Hospital

4.What do you recommend to improve the course?

5.Comments: Please feel free to express any criticism or comments regarding the course.

Thank you very much for taking the time to answer these questions.
Please turn in your post-test and this evaluation before you leave.