SAMPLE EVALUATION FORM
Enhancing Agency Cultural Competence: Part I and II
We appreciate your help in evaluating this program. Please indicate your rating of the
presentation in the categories below by circling the appropriate number, using a scale of (1
lowest rating) through 5 (highest rating). Please fill out both sides of this form. Thank You.
OBJECTIVES: At the end of this training the learner will:
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Lowest
Rating
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Lowest
Rating
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5
Highest
Rating
Define culture and ethnicity.
Define cultural competence and identify cultural
competence standards.
Identify the elements of a cultural competence
plan.
Identify immediate next steps to move forward.
Examine language issues in clinical settings.
Discuss tools for cultural competence selfassessment.
Identify data needed for quality improvement.
SPEAKER: PETER J. GUARNACCIA, PH.D.
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Knowledge of subject matter
Content consistent with objectives
Clarity of delivery
Effectiveness of the presentation
Currency of information
Responsive to participant
Ability to utilize appropriate technology to
support participant learning
CONTENT:
Appropriate for participant’s education,
experience and/or licensure level
Consistent with stated objectives
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5
Highest
Rating
TEACHING METHODS:
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Visual aids, handouts, and oral presentations
clarified content
2
Teaching methods were appropriate for subject
matter
3
Suitability and/or usefulness of instructional
materials
COMMENTS:
RELEVANCY:
1
Information could be applied to practice
2
Information could contribute to achieving
personal, professional goals
FACILITY:
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Was adequate and appropriate for session
2
Was comfortable and provided adequate space
3
Instructions for requesting accommodations for
disability (ADA)
Location, facilities, technology and
administration of the program
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This program enhanced my professional expertise
.Substantially
I would recommend this program to others?
.Yes
. Somewhat
.No
.Not sure
COMMENTS/PROGRAM IMPROVEMENTS:
If you would like to comment in person, please feel free to call
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THANK YOU
.Not at all