Form 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative

1.
REQUIRED OMB INFORMATION: 

Indian Health Service (IHS) Clinical Rounds Qualitative Feedback 

Form Approved 
OMB Form No. 0917­0036 
Expiration Date: 

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 0917­0036. The time required to complete this information 
collection is estimated to average 10 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 336­E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer 

2. Personal Information

For a Certificate of Continuing Education, we need the following information about you. This information is required by the 
accrediting bodies and will only be used in reporting information to them. Your personal information will not be shared 
with others or released to anyone. 

1. Complete the following
Full Name
Professional Credential(s)
Email address
Phone number
Street Address
City
State
ZIP Code
Facility Name
Area

2. Select the term(s) that best describes your role:
c Physician
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c Dentist
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c Pharmacist
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c Nurse Practitioner
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c Physician Assistant
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c Registered Nurse
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c Public Health Nurse
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c Case Manager
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c Licensed Practical Nurse
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c Nursing Assistant
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c Site Manager/IT Representative
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c Clinical Applications Coordinator
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c Medical Records
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c GPRA Coordinator
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c Registered Dietitian
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c Other (please describe)
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3. Evaluation

We would appreciate your feedback on this session. Your input will be used to help us improve our materials and 
presentation approach as we continue to offer educational sessions to all throughout all IHS, Tribal and Urban Facilities. 

3. How well did this training session cover the following objectives?
Poor

Fair

Good

Very Good

Excellent

• Learning Objectives:

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Participants will learn how 

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to (TBD).
Participants will recognize 
(TBD).
Participants will learn 
(TBD).
Other (please specify) 

4. Presentation Method

Please rate each of the rows listed below: 

4. Please describe the quality of the presentation materials and methods used in this
training.
Poor

Fair

Good

Very Good

Excellent

Powerpoint Handout

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Pace of Presentation

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Length of Presentation

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5. Please describe the quality of the services used in this training.
The Virtual service was easy 

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Very Good

Excellent

N/A

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to use
The presentation computer 
functioned properly
The teleconference line 
functioned properly
For those who participated 
in the training in a group 
setting, how would you rate 
the setting?

5. Presenter(s) Evaluation

Please rate the presenter(s). 

6. Presenter Information (TBD)
Poor

Fair

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Very Good

Excellent

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Prepared and organized

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Was professional

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Presented information 

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Demonstrated knowledge of 
the subject material
Responsive to audience 
questions and issues

clearly
Made the material 
interesting
Other (please specify) 

6. General Questions

7. Do you intend to change your practice as a result of this activity?
j Yes (If yes, please provide an example of that change in the comment section below)
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j No
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j Maybe
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Comment 

8. Did you perceive any commercial bias toward any particular product or company in any
part of the presentation?

j Yes
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j No
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Comment 

9. What part of the presentation did you find most useful?
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10. What additional information would you have liked to learn?
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11. What additional topics would you recommend for future IHS National Clinical Rounds?
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7. Certificate Information:
Thank You for completing this survey. Click the link below for the appropriate certificate. 
If you are requesting certificate of completion, please click here for your certificate. 
If you have difficulty please contact Alaina George at alaina.george@ihs.gov .