Form #6 Form #6 Training Evaluation

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

HEALTHCARE ASSOCIATED INFECTIONS (HAI) PROJECT:

TRAINING EVALUATION

Thank you for participating in training on aspects of infection prevention at your facility and in your work as part of a project to identify factors associated with the implementation of training that can assist facilities in successfully preventing infections associated with the process of care and sustaining these reductions. It will take about approximately10 minutes to complete this form after you have been through training. All the answers you give are CONFIDENTIAL. Individual responses will not be shared. We are requesting identification information for data-coding use only. Thank you very much for agreeing to participate in this project.

Today’s date: HAI Master Site Name:

NOTE: Contractors may prepopulate this line

This site’s name and location: What is your position at this facility? (Please mark one.)
(facility and unit, if applicable)

Nurse Pharmacist

Physician (attending/staff) Healthcare aide

Resident/intern Hospital administration

Physician assistant Risk manager

Respiratory therapist Patient safety/quality officer

Other, specify:

1. The HAI Project consists of 3 training tools. For the training which you completed today, please indicate
your overall opinion about the tool(s).

Training Tool	Extremely useful (5)	Very useful (4)	Useful (3)	Minimally useful (2)	Not Useful (1)
a. Chest Tube Insertion CD
b. Central Venous Catheter (CVC) CD
c. Safe Critical Care Education [Blood Stream Infection (BSI) and Ventilator-Associated Pneumonia (VAP)]

Please indicate your assessment of various aspects of the training by marking an X in the box under the response which indicates your agreement with the statement. Please choose one response for each statement.

	Yes, all new and informative (5)	Yes, mostly new and informative (4)	Somewhat new and informative (3)	Minimally new and informative (2)	Not at all new and informative (1)
2. The information in this training was new for me.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

	Extremely relevant and useful (5)	Very relevant and useful (4)	Somewhat relevant and useful (3)	Minimally relevant and useful (2)	Not at all relevant and useful (1)
2. Compared to other infection prevention training I have taken on this subject, this training was:

	Extremely easily (5)	Very easily (4)	Somewhat easily (3)	Not very easily (2)	Not at all (1)
3. I will integrate the knowledge and information I learned today into my daily work practice right away.

	Yes, very supportive (5)	Yes, supportive (4)	Somewhat (3)	Not very supportive (2)	Not at all supportive (1)
4. I have a supportive work-team environment which makes it easy to put new knowledge into practice.

	Strongly agree (5)	Agree (4)	Somewhat agree (3)	Disagree (2)	Strongly disagree (1)
5. This training continues to reinforce to me that my facility is committed to ensuring patient safety.
6. I took this training because it was mandatory.

ADDITIONAL COMMENTS:

7. What aspects of this training did you find helpful?

8. What suggestions do you have for improving this specific training (e.g., how it was administered, reinforcing
content, etc)?

9. Suggestions for other training topics you would like to see offered:

10. Other comments or suggestions you’d like to note: