Facilitator Feedback Forms (10 forms)

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 1 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…
1. How much of this activity did
you complete?

a. Introduction to BodyWorks—discussion
and PowerPoint presentation
b. Discussion on the benefits and barriers
to change
c.

Discussion on behavior change

d. Activity on how to set goals

†
†
†
†
†
†
†
†

None
Some
None
Some
None
Some
None
Some

†
†
†
†
†
†
†
†

Most
All
Most
All
Most
All
Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely

†
†
†
†
†
†

†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

3. How engaged were the
participants in the activity?

†
†
†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

†
†
†
†
†
†
†
†

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 2 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…
1. How much of this activity did
you complete?

a. Discussion on how participants
presented BodyWorks to their families
b. Discussion on healthy weight and the
risks of overweight
c.

Discussion on eating and emotions

d. Demonstration on how to use the
BodyWorks journals

†
†
†
†
†
†
†
†

None
Some
None
Some
None
Some
None
Some

†
†
†
†
†
†
†
†

Most
All
Most
All
Most
All
Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely

†
†
†
†
†
†

†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

3. How engaged were the
participants in the activity?

†
†
†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

†
†
†
†
†
†
†
†

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 3 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…

Most
All
Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely
† Not at all
† Quite a lot
† Somewhat
† Completely

Most
All

†
†

1. How much of this activity did
you complete?

a. Review of first week using the daily
journals
b. Healthy smoothie demonstration
c.

Discussion on the basics of healthy
eating for children, teens, and adults

†
†
†
†
†
†

None
Some
None
Some
None
Some

†
†
†
†
†
†

†
†

Not at all
Somewhat

Quite a lot
Completely

3. How engaged were the
participants in the activity?

†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

†
†
†
†
†
†

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 4 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…
1. How much of this activity
did you complete?

a.

Serving size activity

b.

Review of serving size information

c.

Review of facts about fat

d.

Discussion on making healthy lunch choices

e.

Discussion on making healthy fast food and
beverage choices

†
†
†
†
†
†
†
†
†
†

None
Some
None
Some
None
Some
None
Some
None
Some

†
†
†
†
†
†
†
†
†
†

Most
All
Most
All
Most
All
Most
All
Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely
† Not at all
† Quite a lot
† Somewhat
† Completely

†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

†
†
†
†
†
†

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

3. How engaged were the
participants in the activity?

†
†
†
†
†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

†
†
†
†
†
†
†
†
†
†

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 5 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…

Most
All
Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely
† Not at all
† Quite a lot
† Somewhat
† Completely

Most
All

†
†

1. How much of this activity did
you complete?

a. Discussion on physical activity barriers
and benefits
b. Discussion on types of physical activity
c.

Limiting screen time--discussion and
case study

†
†
†
†
†
†

None
Some
None
Some
None
Some

†
†
†
†
†
†

†
†

Not at all
Somewhat

Quite a lot
Completely

3. How engaged were the
participants in the activity?

†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

†
†
†
†
†
†

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 6 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…

Most
All

None
Some

†
†
†
†

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely

Most
All

†
†

Not at all
Somewhat

†
†

None
Some

†
†

Most
All

†
†

Not at all
Somewhat

†
†

1. How much of this activity did
you complete?

a. Activity to set family goals
b. Activity to learn how to use the weekly
planner magnet
c.

Discussion on involving the family in
planning, shopping, and cooking

†
†
†
†

None
Some

†
†

3. How engaged were the
participants in the activity?
Not at all
Somewhat

Quite a lot
Completely

†
†
†
†

Quite a lot
Completely

Not at all
Somewhat

†
†
†
†

Quite a lot
Completely

†
†

Not at all
Somewhat

†
†

Quite a lot
Completely

Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 7 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…
1. How much of this activity did
you complete?

a. “Let’s Shop, Cook, and Eat Together”
DVD—viewing and discussion
b. Review of how to read nutrition labels

†
†
†
†

None
Some
None
Some

†
†
†
†

Most
All
Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely
† Not at all
† Quite a lot
† Somewhat
† Completely

3. How engaged were the
participants in the activity?

†
†
†
†

Not at all
Somewhat
Not at all
Somewhat

†
†
†
†

Quite a lot
Completely
Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 8 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…

a. Viewing of the “Let’s Shop, Cook, and
Eat Together” DVD

†
†

None
Some

†
†

Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely

b. Discussion on DVD content about
cooking healthy meals and the
BodyWorks recipe book

†
†

None
Some

†
†

Most
All

†
†

Not at all
Somewhat

†
†

c.

†
†

None
Some

†
†

Most
All

†
†

Not at all
Somewhat

†
†

1. How much of this activity did
you complete?

Discussion on DVD and BodyBasics
content about the importance of eating
together as a family

3. How engaged were the
participants in the activity?

†
†

Not at all
Somewhat

†
†

Quite a lot
Completely

Quite a lot
Completely

†
†

Not at all
Somewhat

†
†

Quite a lot
Completely

Quite a lot
Completely

†
†

Not at all
Somewhat

†
†

Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

Did you modify any of the activities?
† Yes † No
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 9 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…

Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely

Most
All

†
†

1. How much of this activity did
you complete?

a.

Environmental checklist activity

b.

Goal setting for environmental issues
activity

†
†
†
†

None
Some
None
Some

†
†
†
†

†
†

Not at all
Somewhat

Quite a lot
Completely

3. How engaged were the
participants in the activity?

†
†
†
†

Not at all
Somewhat
Not at all
Somewhat

†
†
†
†

Quite a lot
Completely
Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11

Parent BodyWorks Session 10 Fidelity Form
Today’s Date:

Session Location:

Trainer(s):

Start Time:

End Time:

I. Please check “No” or “Yes” to indicate whether you implemented the following activities during this session…
Welcome and ‘How am I doing?’:  … No … Yes

Journal review: … No … Yes 

Review of previous session: … No … Yes 

Energizer and healthy snack: … No … Yes 

What did you learn today?: … No … Yes 

 Assign homework: … No … Yes

If you did NOT implement one or more of these activities, please explain why:
II. Please share your reactions to the following activities…
1. How much of this activity did
you complete?

a.

Media literacy quiz

b.

Activity analyzing a tobacco ad

c.

Handout and discussion on types of
advertising techniques

d.

Activity analyzing a magazine ad

†
†
†
†
†
†
†
†

None
Some
None
Some
None
Some
None
Some

†
†
†
†
†
†
†
†

Most
All
Most
All
Most
All
Most
All

2. To what extent did the activity
help achieve the session learning
objectives?
† Not at all
† Quite a lot
† Somewhat
† Completely
† Not at all
† Quite a lot
† Somewhat
† Completely

†
†
†
†

†
†
†
†

Not at all
Somewhat
Not at all
Somewhat

Quite a lot
Completely
Quite a lot
Completely

3. How engaged were the
participants in the activity?

†
†
†
†
†
†
†
†

Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat
Not at all
Somewhat

†
†
†
†
†
†
†
†

Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely
Quite a lot
Completely

III. Please share how you modified the activities.
a.
b.

† Yes † No
Did you modify any of the activities?
If yes, please explain why and how the activities were modified. ___________________________________________________________________

IV. Please share your reactions to the following statements…
Strongly
Disagree

Disagree

Agree

Strongly
Agree

a.

The lesson plan, background materials, and support I received prepared me well to teach
this session.

b.

I felt confident in my ability to implement this session.

V. Please tell us what worked well and what should be improved.
a.

What worked well? _____________________________________________________________________________________________________________

b.

What should be improved? _______________________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer