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 Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) 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 Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip Phone Fax Email
Family physician Resident Medical student School nurse Physician assistant Health educator Other (please identify)
2. Where do you live?
City State Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose)
Yes No
4. Was the Tar Wars Program Guide useful in helping you prepare for your presentation?
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.
Number of years
Number of times this year
Number of students
11. Did you encounter any problems in making contact with your coordinator or the school? If so, please explain.
Name Address City State Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip Phone Fax Email
