Bodyworks program particpants -Feedback forms

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Form Approved OMB No. 0990-xxxx

Exp. Date xx/xx/xxxx

odyWorks Participant Session Survey

Today’s Date: ___________		Session Number: ______	Program Location: ________________________			Trainer Name(s): ________________
If you are a PARENT or CAREGIVER:	Your Initials [Jane Smith is J.S; Jane Doe-Smith is J.D.] ___ ___			Birthday Child/Teen #1 ______ / ______ / _______ MM DD YY	Birthday Child/Teen #2 ______ / ______ / _______ MM DD YY		Birthday Child/Teen #3 ______ / ______ / _______ MM DD YY
If you are a CHILD/TEEN:	Your Parent/Caregiver’s Initials [Jane Smith is J.S; Jane Doe-Smith is J.D.] ___ ___			Your Birthday ______ / ______ / _______ MM DD YY

1. What activities did you do today? (Choose one or more.)
 Reviewed what we already learned	 Heard a presentation	 Did physical activity
 Had a group discussion	 Watched a video	 Had a snack
 Hands-on or group activity	 Used a toolkit item, like the journal or recipe book	 Made food
 Other (please specify):

2. What topics did you talk about today? (Choose one or more.)
 Healthy eating  Physical activity  Changing behaviors	 Journaling  Goal-setting  Body image and eating disorders	 Advertising and the media  Other (please specify):

3a. How easy to understand was today’s session?	3b. How interested were you in today’s session?	3c. How much did you learn from today’s session?	3d. How satisfied were you with today’s session?
Not easy to understand Somewhat easy to understand Very easy understand	Not at all interested Somewhat Interested Very interested	No new information Some new information A lot of new information	Not at all satisfied Somewhat satisfied Very satisfied

4a. What did you like about today’s session? (Use the back of this page if you need more space.)

4b. What should be changed in today’s session? (Use the back of this page if you need more space.)

5. Think about all of the BodyWorks sessions you have attended so far. On a scale of 1 – 10, with 1 being “not at all satisfied” and 10 being “very satisfied,” please rate how satisfied you are with the entire BodyWorks program.
Not at all satisfied													Very satisfied
	1	2	3		4		5	6		7		8		9	10

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-xxxx . The time required to complete this information collection is estimated to average 5 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.