Form 10-10114 National Family Caregiver Participant Training Feedback

National Family Caregiver Comprehensive Training Program Participant Feedback Form OMB 2900-0770

Estimated Burden 10 min.

EXP Date: XX/XX/XXXX

National Family Caregiver
Comprehensive Training Program

Participant Feedback Form

VA Form 10-10114

OMB 2900-0770

Estimated Burden 10 min.

E XP DATE: XX/XX/XXXX

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will average 10 minutes. This includes the time it will take to read instructions, gather facts and fill out the form. The Participant Feedback Form will be used to gauge customer perceptions of VA Caregiver training services and program satisfaction. The results of this feedback will lead to improvement in the quality of service delivery by helping to shape the direction and focus of specific programs or services. Completion of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

1. Please select one:

□ I am the Primary Family Caregiver

□ I am a Secondary Family Caregiver

2. Please select from the list below what best describes your relationship to the Veteran

□ Spouse/partner

□ Son/Daughter/Stepchild

□ Other relative: _____________

□ Friend

3. Please select from below, the method you used to complete Caregiver Training

□ Online

□ Workbook

□ Classroom

4. To what extent do you agree with the following statements?

4a. The Caregiver training increased my knowledge and skill in caring for the Veteran.

 Strongly Agree

 Agree

 Undecided

 Disagree

 Strongly Disagree

4b. The Caregiver training improved my knowledge and ability to take care of my physical
and emotional health.

 Strongly Agree

 Agree

 Undecided

 Disagree

 Strongly Disagree

.

5. On a scale of 1 to 5, please rate your overall satisfaction with this training.
Please circle your response with 1 being not satisfied and 5 being extremely satisfied.

1 2 3 4 5

6. Did the training provide new information about Caregiving that would assist you in caring for the Veteran?

□ Yes

□ No

6a. If yes, please comment on the new information.

7. Did the training provide new information about caregiving resources that you had not known about?

□ Yes

□ No

7a. If yes, which new resource(s) do you plan to use.

8. Do you feel more confident in your overall caregiving capacity as a result of participating
in this Caregiver training program?

□ Yes

□ No

.

9. Please rank the course modules from 1-6. (1 being most useful and 6 being least useful)

Caregiver Self-Care ____

Home Safety and Emergency Preparedness ____

Caregiver Skills ____

Veteran Personal Care ____

Managing Challenging Behaviors ____

Resources for Advocacy ____

10. Please comment on reason for modules ranked #1 and #6

Module Ranked #1_________________________

Module Ranked #6_________________________

11. Would you have liked more detail on any specific topic/module(s)? If yes, please describe:

□ Yes

□ No

12. Would you have liked less detail on any specific topic/module(s)? If yes, please describe:

□ Yes

□ No

13. Additional suggestions to strengthen and/or improve this Caregiver training program?

Thank you for taking the time to complete the feedback form.

Your feedback will allow us to better improve our training.

VA Form 10-10114
July 2014