American Liver Foundation: Survey - Love Your Liver Program Evaluation Form

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Love Your Liver 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):

*5.

Question - Required - Rate your knowledge BEFORE this program: Excellent
Very Good
Good
Fair
Bad
No Answer

*6.

Question - Required - Rate your knowledge AFTER this program: Excellent
Very Good
Good
Fair
Bad
No Answer

*7.

Question - Required - How was the speaker? Excellent
Very Good
Good
Fair
Bad
No Answer

*8.

Question - Required - How was the information in the presentation: Excellent
Very Good
Good
Fair
Bad
No Answer

*9.

What topics would you want to hear more about?

(Select one of the available choices or enter a different value.)
Question - Required -

TELL US ABOUT YOU:

10.

Question - Not Required - How old are you? 13 and under
14 - 18
over 18

11.

Question - Not Required - Gender: Male
Female

12.

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

13.

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

14.

Question - Not Required - What is your primary language?

OFFICE USE ONLY

*15.

Question - Required - Division Office Code:

*16.

Question - Required - Staff Entering Data: