Educational Exchange Experience Evaluation

Please complete this form to help us evaluate the NOSORH Educational Exchange program. Please complete the evaluation in full and submit when completed. This form must be completed in addition to the reimbursement form to receive travel reimbursement from NOSORH.

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* 1. Traveler Contact Information

Name

State/Province

Email Address

Phone Number

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* 2. Resource Contact Information

Organization that provided the educational exchange:

Name of person(s) who provided the educational exchange:

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* 3. How would you rate your knowledge of the content...

	No Knowledge	Some Knowledge	Moderate Knowledge	Considerable Knowledge	Expert Knowledge
Before the Visit	Before the Visit No Knowledge	Before the Visit Some Knowledge	Before the Visit Moderate Knowledge	Before the Visit Considerable Knowledge	Before the Visit Expert Knowledge
After the Visit	After the Visit No Knowledge	After the Visit Some Knowledge	After the Visit Moderate Knowledge	After the Visit Considerable Knowledge	After the Visit Expert Knowledge

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* 4. How would you rate the accomplishment of your learning objectives?

Did not meet learning objectives

Partially met learning objectives

Completely met learning objectives

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* 5. If you did NOT completely meet objectives, what activities did not occur?

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* 6. How do you plan to utilize the information gathered from your educational experience? (check all that apply)

Share with staff

Share with rural communities

Share with partners (e.g., state primary care association)

Track the issue or learn more about it

Initiate an activity such as investigating or starting a new program or changing an existing program

Please describe:

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* 7. What was your overall response to this educational exchange?

Unsatisfactory

Satisfactory

Excellent

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* 8. Do you anticipate an ongoing relationship with your mentor or peer resource?

Yes

Please describe:

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* 9. May we share your responses with your peer resource?

Yes

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* 10. Would you be willing to share in a similar experience with another SORH?

Yes

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* 11. Did you experience any challenges in utilizing the Educational Exchange program or the training provided through the program?

Yes

If yes, please describe your challenges

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* 1. Traveler Contact Information

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* 2. Resource Contact Information

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* 3. How would you rate your knowledge of the content...

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* 4. How would you rate the accomplishment of your learning objectives?

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* 5. If you did NOT completely meet objectives, what activities did not occur?

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* 6. How do you plan to utilize the information gathered from your educational experience? (check all that apply)

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* 7. What was your overall response to this educational exchange?

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* 8. Do you anticipate an ongoing relationship with your mentor or peer resource?

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* 9. May we share your responses with your peer resource?

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* 10. Would you be willing to share in a similar experience with another SORH?

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* 11. Did you experience any challenges in utilizing the Educational Exchange program or the training provided through the program?

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* 12. Please provide any suggestions you have for improving the Educational Exchange program: