Family/Public Medical Program Evaluation

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Tourette Syndrome Association Family/Public Program Evaluation - Medical

Date/Location

Speaker

Program objectives -Participants will learn to:

• Identify the basic signs of TS and co-occurring conditions

• Describe medical and/or behavioral treatment options

• Locate support resources available through TSA

• Educate medical providers/teachers/employers and others about TS

Participants will receive:

• Information and support to address and help with a family issue (and decrease family burden)

1. Please indicate your relation to someone with Tourette Syndrome. Check all that apply.

Self Parent Other relative Friend Teacher Service Provider

General Interest in TS Other __________

2. What were your main reasons for coming today? Check all that apply.

Need new information Meet other people with TS Newly Diagnosed Access to a specialist Other _____

3. How much of this content was new to you? Almost all____ 75%____ 50%____ 25%____ Almost none____

4. Please rate your knowledge in the following areas, before and after participating in this program

Knowledge BEFORE today’s program			Self-assessment of your knowledge related to:	Knowledge AFTER today’s program
None	Some	A lot		None	Some	A lot
1	2	3	Diagnosis/Recognition of TS	1	2	3
1	2	3	Common conditions that occur with TS	1	2	3
1	2	3	Medical Treatment Options	1	2	3
1	2	3	Behavioral Treatment options	1	2	3

5. Please rate the following statements

	Strongly agree	Agree	Disagree	Strongly disagree	Does not apply
a. I plan to share the information I learned with my/my child’s school
b. I plan to share the information I learned with my/my child’s healthcare provider
c. I feel better able to cope with issues related to my/my child’s TS
d. I plan to use some of the information I learned to help with an individual or family need or concern
e. The presenter communicated the content effectively
f. Feedback (Q&A) I received during the activity was helpful

6. Please rate the following statements before and after your participation in this program

BEFORE today’s program			Rate the following statements:	AFTER today’s program
Don’t know where to go	Can find some information	Know where to go	I know where to go for more information	Don’t know where to go	Can find some information	Know where to go
No connection	Somewhat connected	Very connected	I feel a sense of connection with other affected persons/families	No connection	Somewhat connected	Very connected
Not prepared	Somewhat prepared	Very prepared	I am prepared to educate others about TS	Not prepared	Somewhat prepared	Very prepared
Very stressed	Somewhat stressed	No stress	I feel stress related to one of more TS issues	Very stressed	Somewhat stressed	No stress

Suggestions to improve this program:

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D- 74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).