American Liver Foundation: Survey - Viral Hepatitis Program Evaluation Form

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Viral Hepatitis Program Evaluation Form

*1.

Question - Required - Program Date:

Month

Day

Year

*2.

Question - Required - Program Educator:

*3.

Question - Required - Program Location Name:

*4.

Question - Required - Program Location (City, State):

KNOWLEDGE BEFORE EDUCATION PROGRAM

Question - Not Required - Before listening to this program, what was your understanding about Viral Hepatitis? Not at all
Somewhat
Mostly
Completely

KNOWLEDGE AFTER EDUCATION PROGRAM

Question - Not Required - The education program answered my questions and concerns about Viral Hepatitis: Not at all
Somewhat
Mostly
Completely

Question - Not Required - I now know the risk factors for Hepatitis A: Not at all
Somewhat
Mostly
Completely

Question - Not Required - I now know the risk factors for Hepatitis B: Not at all
Somewhat
Mostly
Completely

Question - Not Required - I now know the risk factors for Hepatitis C: Not at all
Somewhat
Mostly
Completely

10.

Question - Not Required - I now know the importance of speaking to my health care provider, if I have a risk factor: Not at all
Somewhat
Mostly
Completely

11.

Question - Not Required - I now understand how to prevent the spread of Hepatitis A: Not at all
Somewhat
Mostly
Completely

12.

Question - Not Required - I now understand how to prevent the spread of Hepatitis B: Not at all
Somewhat
Mostly
Completely

13.

Question - Not Required - I now understand how to prevent the spread of Hepatitis C: Not at all
Somewhat
Mostly
Completely

14.

Question - Not Required - I now have a good idea about treatment options for Hepatitis C: Not at all
Somewhat
Mostly
Completely

15.

Question - Not Required - The educator did a good job of communicating the information: Not at all
Somewhat
Mostly
Completely

16.

Question - Not Required - What additional information would you want to see included in this presentation?

(Maximum response 255 chars, approx. 5 rows of text)

17.

Question - Not Required - How can we improve this presentation?

(Maximum response 255 chars, approx. 5 rows of text)

TELL US ABOUT YOU:

18.

Question - Not Required - How old are you? Under 18
18 - 25
26 - 30
31 - 49
50 - 65
65+

19.

Question - Not Required - Gender: Male
Female

20.

Question - Not Required - Race: Hispanic or Latino
White
Black or African-American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Two or More Races
Other

21.

Question - Not Required - Ethnicity (examples include: Mexican, Korean, Colombian):

22.

Question - Not Required - What is your primary language?

23.

Question - Not Required - Are you a: Patient
Family Member/Caregiver
Medical Professional
General Audience
Social Service Provider
Other

JOIN THE AMERICAN LIVER FOUNDATION - OPTIONAL AND CONFIDENTIAL

24.

Question - Not Required - Would you like to receive more information about liver wellness and liver disease?

25.

Question - Not Required - Would you like to become more involved and/or volunteer with your local American Liver Foundation division? (If yes, please fill out your contact information below.)

26.

Contact Information:

Name:

First Required	Last Required

Email:

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Phone Number:

Yes, I would like to receive e-mail from American Liver Foundation

Yes, I would like to receive postal mail from American Liver Foundation

OFFICE USE ONLY

*27.

Question - Required - Office Division Code:

*28.

Question - Required - Staff Entering Data: