View, Download, and Print Facilitator Evaluation pdf

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.