October, 2017

Sample Provider–Directed Evaluation Summary Tool Format

Title of Education Activity:

Location: Date:

Learning Outcome(s):

Please complete this evaluation questionnaire. Your anonymous responses will be used to revise this activity and to plan future education activities. Circle the number that best fits your evaluation of this activity. 1 = Not at all 2 = Somewhat 3 = Almost completely 4 = Completely 1. Were the teaching methods/learner engagement strategies used by each presenter effective in meeting the learning outcome: a. (State name of presenter) 1 2 3 4 b. (State name of presenter) 1 2 3 4

2.Was the learning outcome met? Yes No

3. As a result of this activity, do you intend to make any changes to your professional practice/performance? Please circle your answer. Yes No  If no, why not? ______ If yes, identify changes you intend to make:

 What potential barriers do you see to applying the new strategies/knowledge gained from this activity?

4. Did you, as a participant, notice any bias that was not previously disclosed in this presentation? Yes No If “Yes”, please describe who was biased and how.

5. Based on today’s activity, please list additional learning needs that you might have.

Additional Comments:

Rev 100617 Page | 1 Planning Committee Review

Based upon review of the planning committee: 1. Was the learning outcome of the activity met? (Was the professional practice gap narrowed or closed?) Yes _____ No _____

2. What was the impact of this activity on nursing professional development and/or patient outcomes?   

3. What went well with the activity?

4. Where are there opportunities for improvement?

5. What changes do you plan to make based on your evaluation of this activity?  To this activity:

 To future activities: