Surveys for Building Your Wellness Toolbox (A six week psycho-educational group as part of the Promoting Older Women's Engagement in Recovery project)

Form Approved

OMB No. 0990-

Exp. Date 06/30/2020

Building Your Wellness Toolbox – Evaluation, Session 5

Please complete this evaluation for the group session you just participated in. Your responses will help us to understand how best to support wellness among women aged 55+. IHR relies on your honest opinions & suggestions for improving this group offering.

From your participation in this session, please rate how much you agree or disagree with the following statements:

	Strongly Disagree	Disagree	Agree	Strongly Agree
I know more about non-pharmacological (non-medication) options for pain.				
I am more aware of community resources for alternative pain management practices (e.g. physical therapy, acupuncture, yoga).				

After participating in this session, how likely are you to use the following pain management strategies?

	Not likely	Slightly likely	Somewhat likely	Very likely
Prescription opioids				
Other pain medications				
Non-medication alternatives				

Would you like one of the group facilitators to follow up with you individually about anything discussed today?  Yes  No

• If yes, what issues would you like to address with them? ___________________

__________________________________________________________________________________________________________________________________________________

Do you need help connecting to any resources or services? _________________________

__________________________________________________________________________________________________________________________________________________

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 0990-0379. The time required to complete this information collection is estimated to average 9 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete 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 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer