<p>Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians, Feedback form for Participants, July 2002 Please use this form to provide the Northwest Center for Public Health Practice with feedback about this training curriculum. (Please note this is not the appropriate evaluation form for individuals requesting CME credit, see nwcphp.org/bttrain/cme/ for CME forms.)</p><p>Please return the completed form to: Northwest Center for Public Health Practice By Mail: School of Public Health and Community University of Washington 1107 NE 45th St., Suite 400 Seattle, WA 98195 By Email: [email protected]</p><p>Thank you!</p><p>Feedback Form for Participants</p><p>1) Are you a a. Physician (MD, DO) b. Nurse Practitioner c. Physician Assistant d. Other – please specify</p><p>2) Which of the following best describes your practice/work setting? a. Urban b. Suburban c. Rural d. Other – please specify</p><p>3) Which of the following best describes your practice type? a. Primary care solo practice b. Primary care group practice c. Multi-specialty group practice d. Hospital-based practice e. Community health center or public health clinic f. Other – please specify g. Not applicable</p><p>4) Which of the following best describes your field of medicine? a. Family practice b. Internal medicine c. Pediatrics d. Other – please specify e. Not applicable Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians, Feedback form for Participants, July 2002 5) What bioterrorism-related education or training have you received prior to participation in this course? a. Articles in scientific journals b. CDC satellite/web-based broadcasts c. Lectures given at hospital or practice facility d. USAMRIID Medical Management of Biological Casualties course e. Other (please specify) f. No previous BT-related training or education prior to this course </p><p>6) What is your primary purpose/reason for participating in this course? ______</p><p>7) Please check all of the modules from this course that you attended: a. Introduction to Bioterrorism b. Bioterrorism Preparedness and Response c. Diseases of Bioterrorist Potential: Anthrax d. Diseases of Bioterrorist Potential: Smallpox e. Diseases of Bioterrorist Potential: Plague and Botulism f. Diseases of Bioterrorist Potential: Tularemia and Viral Hemorrhagic Fevers g. Psychological Aftermath of Crisis</p><p>8) How would you rate this course overall? a. Excellent b. Very good c. Good d. Fair e. Poor</p><p>9) How confident did you feel, prior to taking this course, in your ability to diagnose and treat illness caused by the Category A agents? a. Very confident b. Somewhat confident c. Not confident at all d. Unsure (please explain) e. Not applicable Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians, Feedback form for Participants, July 2002 10) How confident do you feel now in your ability to diagnose and treat illness caused by the Category A agents? a. Very confident b. Somewhat confident c. Not confident at all d. Unsure (please explain) e. Not applicable </p><p>11) How confident did you feel, prior to taking this course, in your ability to respond (i.e., as a clinician) to a bioterrorism incident? a. Very confident b. Somewhat confident c. Not confident at all d. Unsure (please explain)</p><p>12) How confident do you feel now in your ability to respond to a bioterrorism incident? a. Very confident b. Somewhat confident c. Not confident at all d. Unsure (please explain)</p><p>13) Did this course meet your objectives? (yes/no/some but not all) Please explain______</p><p>14) What are positive aspects of this course? Negative aspects? Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians, Feedback form for Participants, July 2002 15) What could be done to improve the course? </p><p>16) Would you be interested in teaching this course? </p>