North Carolina Asthma Program: The North Carolina Asthma Plan Evaluation Form

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Datos Básicos sobre el Asma

Thank you for taking time to read the North Carolina Asthma Plan. In order to help us evaluate the plan and improve future editions, please complete and submit the short online survey below. Your feedback will be sent to North Carolina Asthma Program staff.

PDF Evaluation Form Option: If you have difficulty with the form below or need or prefer to complete the evaluation by hand, there is also a PDF version available. If you use the PDF version, you will need Adobe Reader. Please return the completed PDF form via fax to 919-870-4801. (Do not save the completed PDF evaluation form to your local hard drive and attach it to an email, as form data cannot be saved to your local hard drive using Adobe Reader. If you require additional help submitting the form, please call 919-707-5210.)

Thank you in advance for your feedback.

The North Carolina Asthma Plan: Evaluation Form

In order to complete this evaluation, you must have a Javascript-enabled browser. If a Javascript-enabled browser is not available to you, please download the PDF version of this form, complete, and return via fax to 919-870-4801.To enable Javascript:

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If there is an asterisk "*" at the end of question, it means an answer is required. We ask that you complete questions 1-6. Questions 7, 8, and 9 are optional.

1. What type of organization do you represent (check all that apply): *

Local Health Department
State or Local Coalition
Community Health Organization
Hospital
Clinic or Medical Practice
Academic Institution (College, University)
Elementary/Secondary School
Medical/Health Professional Association
Faith Based Organization
Person with Asthma
Parent of Child with Asthma
OTHER

2. Name of organization (optional):

3. What is your position in the organization (check all that apply): *

Physician
Nurse
Health Educator
Epidemiologist
Researcher
Faculty
Community Leader
Government Official
Legislator
Administrator
OTHER

4. How will you use this plan (check all that apply): *

Priority-Setting
Community-level Strategic Planning
Presentations
Grant Writing
Coalition Development
Educational Materials
OTHER

5. For each statement below, please select the choice that best reflects your opinion: *

a. This plan is clear and easy to understand.

b. This plan is well-organized.

c. The plan reflects the issues most important to addressing asthma in North Carolina..

d. The plan has helped me to structure and develop my asthma-related activities and interventions..

6. Please rate the usefulness of each section: *

a. The Executive Summary was:

b. Asthma is a Public Health Priority was:

c. The Burden of Asthma in North Carolina was:

d. The Planning Process was:

e. The Strategic Plan (by topic area):

1. Education and Public Awareness:

2. Health Disparities:

3. Medical Management:

4. Surveillance:

5. Environmental:

f. The Evaluation Plan was:

7. Please list any other content areas that you would like to see represented in future editions of the plan:

(You may enter up to 250 characters.)

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8. Please list any organizations (name, phone #, email address) you feel would benefit from this plan:

(You may enter up to 250 characters.)

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9. Other comments/suggestions:

(You may enter up to 250 characters.)

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