Community Health Care Association of New York State (CHCANYS)

EMERGENCY PREPAREDNESS LEARNING CALL
November 2007

EVALUATION FORM 

Please take a moment to complete this brief form.  It is important for the development of future programs.
Responses may be faxed to 212-279-3851 or e-mailed to cnicholson@chcanys.org 
Thank you!

1.)  Please give us your thoughts on the (11/9/07) Emergency Preparedness call: 

2.)  Please rate the call by checking (√) the appropriate box.

	5
Strongly agree	4
Agree	3
Neutral	2
Disagree	1
Strongly disagree	
Communication was clear and effective.						
Information was useful.						
My questions were answered.						

3.)  Please list any additional questions you & your site have following the 11/9/07 call:

4.)  Please provide any EMERGENCY PREPAREDNESS TOPICS you & your site would like discussed on future learning calls:

5.)  Do you need additional EP resources (e.g. Emergency Management Plan, DVDs, Videos, CDs, Toolkits, HVA spreadsheet, etc.)?

If so, please indicate: 
Materials& Quantities needed:	________________________________________________________________________

Mailing address:	_______________________________________________________________________________

			_______________________________________________________________________________

			_______________________________________________________________________________

or email:		_______________________________________________________________________________

Please note contact information may be sent separately if you would like to maintain anonymity.