American Academy of Family Physicians

Presentation Questionnaire for Teachers

1. What is the name of your school?
School name
2. Where is your school located?
City
State
3. What grade do you teach? (check all that apply)
4th
5th
Other

4. Were you pleased with your presenter and their presentation?

Yes
No

5. If no, why not?

6. Was the Tar Wars Program Guide useful in helping you understand the program objectives and your responsibilities?
Yes
No

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

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

8. If no, please explain.

9. Did you encounter any problems in making contact with your state coordinator or the presenter? If so, please explain.
10. Do you have any suggestions for improving the Tar Wars Program Guide or Lesson Plan?
11. Please provide us with your contact information:
Name
Address
City
State
Zip
Phone
Fax
Email