Presentation Questionnaire for Presenters

1. I am a:
Family physician
Resident
Medical student
School nurse
Physician assistant
Health educator
Other (please identify)

2. Where do you live?

City
State


3. Are photos of your presentation available?
Yes
No

4. Was the Tar Wars Program Guide useful in helping you prepare for your presentation?

Yes
No

5. If yes, how useful would you rate it?

5-Very useful
4
3-Somewhat useful
2
1-Not useful

6. If no, please explain.

7. How many years have you presented Tar Wars? (enter a whole number only, no punctuation, e.g., “3")
Number of years
8. How many times have you presented Tar Wars this year?
Number of times this year
9. How many students would you estimate you have reached this year with your presentation(s)?
Number of students
10. Did you contact your state coordinator prior to presenting in the classroom?
Yes
No

11. Did you encounter any problems in making contact with your coordinator or the school? If so, please explain.

12. Do you have any suggestions for improving the Tar Wars Program Guide or Lesson Plan?
13. Please provide us with your contact information:
Name
Address
City
State
Zip
Phone
Fax
Email