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Montana State University Extension

Prescription Opioid and Stimulant Education & Awareness Parental Awareness and Action Training Module - 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 stimulants and the potential hazards associated with these medications. 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):  ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

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 training module that you omitted or modified? If so, please describe these changes and why you made them.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Did you present this module yourself or did you use the pre-recorded slideshow?

  • 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:

HANDOUTS:                                                                                                            

Talking With Adolescents About Opioid and Stimulant Misuse

    • Utilized (yes/no)__________  
    • # Distributed___________

DEA Counterfeit Pills Fact Sheet (Dec 2021)

  • Utilized (yes/no)__________  
  • # Distributed___________

Emoji Drug Code: Decoded Handout                                                                                                                                             

  • Utilized (yes/no)__________  
  • # Distributed___________

Prescription Opioid and Stimulant Misuse Among Youth Fact Sheet

  • Utilized (yes/no)__________  
  • # Distributed___________

Be Aware of These Common Stimulants Infographic

  • Utilized (yes/no)__________  
  • # Distributed___________

VIDEOS:

Opioid Misuse: A Montanan Discusses the Four Phases of His Recovery From Opioids

  • Utilized (yes/no)__________  

Insight Into the Teenage Brain Video (UCLA researcher and assistant professor Dr. Adriana Galvan) 

  • Utilized (yes/no)__________  

Taking Prescription Opioids Safely

  • Utilized (yes/no)__________  

Taking Prescription Stimulants Safely

  • Utilized (yes/no)__________  

OTHER RESOURCES:

Help Save Lives Act:  Montana Annotated Code 2021

  • Utilized (yes/no)__________  

Module 1: Introduction to Opioids (derived from the Prescription Opioid Awareness and Education Toolkit)

  • Utilized (yes/no)__________  

Additional 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 ([email protected]) 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: [email protected].