How would you like your name to appear on your certificate?

Profession

What activities did you attend at the event?

Introduction and Module 1

Module 2

Module 3

Module 4

Module 5

Module 6

Agreement

By completing this form, you attest that you have participated in all selected activities in thier entirety.

I agree

The instructor was knowledgeable about the content

Objective 1: Learn more about how sexual violence survivors can experience cancer care (e.g., retraumatization).

By meeting the above objective my professional competence will increase because I have acquired new strategies to use in my practice.

By meeting the above objective my professional performance will improve because I should be able to implement the new strategies.

By meeting the above objective my patient outcomes should improve due to the implementation of newly-learned strategies.

The teaching methods used were appropriate to the objectives

The subject matter was presented clearly

Objective 2: Learn sensitive practice skills for working with sexual violence survivors undergoing cancer care.

By meeting the above objective my professional competence will increase because I have acquired new strategies to use in my practice.

By meeting the above objective my professional performance will improve because I should be able to implement the new strategies.

By meeting the above objective my patient outcomes should improve due to the implementation of newly-learned strategies.

The teaching methods used were appropriate to the objectives

At the end of Module 1, trainees will be able to define sexual violence.

To understand the different types of sexual violence and to describe the prevalence of sexual violence.

To understand how sexual violence and cancer intersect.

At the end of Module 3, trainees will be able to understand common stressful situations for sexual violence survivors in healthcare settings (e.g., sensory and relational triggers).

To recognize how those stressful situations may present in cancer care.

At the end of Module 4, trainees will be able to understand triggering and how it can present in cancer care.

Understand dissociation and how it may present in cancer care, and recognize how dissociation can contribute to avoidance of and non-adherence to cancer treatment.

Be familiar with grounding techniques.

At the end of Module 5, trainees will be able to understand how to begin and end cancer care appointments in a sensitive manner.

Understand the concept of ongoing informed consen.

Be familiar with how to conduct task-specific inquiry, and be familiar with the S-A-V-E the situation approach.

At the end of Module 6, trainees will be aware of considerations related to asking patients about a history of sexual violence.

Be aware of how to respond if a patient discloses a sexual violence history during cancer care.

Be aware of reactions to avoid if a patient discloses a sexual violence history during cancer care.

The technology was used effectively

At the end of Module 2, trainees will be able to describe the nine principles of sensitive practice (i.e., the â€œUmbrella of Safetyâ€ principles).

To identify why implementing those principles might be of particular relevance to sexual violence survivors, and to relate those principles to cancer care.

To understand the reasoning behind a universal precaution approach wherein cancer care providers apply sensitive practice principles to all patients.

The technology was used effectively

Please rate the following:

The program was relevant to my work.

Content matched stated objectives.

Usefulness of handouts/AV.

How well did the educational sessions give a balanced view of therapeutic options, including the use of generic names?

If you rated any of the above questions with 'fair,' 'poor,' 'disagree,' or 'strongly disagree' please explain in detail (e.g. session title, speaker name, situation):

Please tell us about any sessions you found particularly good or bad

Please tell us about any objectives you feel we accomplished well or poorly

Please tell us about any presenters you found particularly good or bad

Please answer the following:

Did this program improve your Skill or Strategy in your role or contribution as a member of the healthcare team?

Was the educational content scientifically sound?

If faculty spoke about off-label or investigational uses of a product, was that information disclosed to you?

Was the mode of education effective to learning?

If you answered "No" to any of the above questions, please explain.

Did you perceive any product/service/company/commercial bias in any educational session you attended or materials you received?

If you answered "Yes" to the above question, please detail the situation below (e.g. session title, speaker name):

Were you solicited with sales information while you attended this educational activity?

If you answered "Yes" to the above question, please explain in detail (e.g. who, when, where):

How much did you learn as a result of this education program?

Do you believe your participation in this activity will positively impact your healthcare team?

Yes

No

If yes, how?

If no, why not?

What questions have arisen in your practice for which you need answers/strategies that you can implement?

What patient/client problems or patient/client challenges do you feel you are not able to address appropriately or to your satisfaction?

What problems are your patients/clients communicating to you that need attention or follow up?

Are you interested in basic, intermediate or advanced level trainings?

Basic

Intermediate

Advanced

What barriers might you have that would interfere with implementation of new information learned from this training?

How can this training (the overall activity) be improved to better impact competence, performance and/or patient/client outcomes?

ASRT ID Number, if applicable:

Additional comments: