PERT Curriculum Feedback Form Thank you for using the PERT curriculum. Your analysis and commentary about these materials are very valuable to the PERT Program. Please complete this questionnaire after you have used the PERT Curriculum materials to present an in-service or training. Evaluate the effectiveness of the PERT Curriculum in helping you to increase the knowledge and skills of participants who attended your in-service or educational event. (If you use the PERT Curriculum to provide multiple in-services or trainings, we encourage you to complete this form again for each presentation.) Part A: In-Service Tracking First name:  Last name:  Email address:  Have you used the PERT Curriculum materials? Yes No If you answered NO to the previous question, please provide a brief explanation in the box to the right as to why you did not use the PERT Curriculum materials. Then scroll down to the bottom of the page and click the SUBMIT button. If you answered YES to the previous question, please complete the rest of the questions on this page. Module presented. If you have presented more than one section of the PERT Curriculum, please evaluate the module you have presented most recently. If you would like to provide feedback on more than one module, you are welcome to complete and submit this form again for each module you have used. Please choose from the following Overview Philosophy of Care Hospice Goals of Care Quality Improvement Pain Assessment Pain Management Symptom Management Role of the Nursing Assistant Nondrug Symptom Management Communication Culture Grief and Bereavement Self-Care Spiritual Considerations Ethics A combination of modules Date module presented: Month:   January February March April May June July August September October November December    Day:   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year:   2005 2006 2007 2008 2009 2010 Number of attendees:  Amount of time needed to prepare in-service or training: Less than 1 hour 1 to 2 hours 2 to 4 hours 4 to 6 hours More than 6 hours In addition to the PERT Curriculum materials, did you use any of the following resources? (Check all that apply.) Journal Article Book Website Computer Program Guest Speaker Other Resource Where did you present the PERT Curriculum module? In your facility/agency At another facility/agency In the community In a school or training program Other, please list:  Did you have participants complete the module quiz? Yes No Please evaluate the effectiveness of the PERT Curriculum. Rate how much you agree with each of the following statements, using a scale of 0 to 10, where 0 means disagree strongly and 10 means agree strongly. 1. Using the PERT educational module, I successfully met the objectives of the in-service or training. Disagree strongly Agree strongly 0 1 2 3 4 5 6 7 8 9 10 2. The PERT Curriculum materials are easy to use. Disagree strongly Agree strongly 0 1 2 3 4 5 6 7 8 9 10 3. The PERT Curriculum materials allow me to present information about end-of-life care clearly. Disagree strongly Agree strongly 0 1 2 3 4 5 6 7 8 9 10 4. The PERT Curriculum will assist nursing staff who attended the in-service to provide better care to dying residents and their families. Disagree strongly Agree strongly 0 1 2 3 4 5 6 7 8 9 10 5. The PERT Curriculum materials are up-to-date. Disagree strongly Agree strongly 0 1 2 3 4 5 6 7 8 9 10 Your comments. How can the PERT Curriculum materials be improved to enhance your skill and confidence in increasing the end-of-life knowledge and skills of nursing staff who attend PERT-based trainings or in-services? (Please answer in the box below.) Part B: Trainer Self-Evaluation Please assess your skills in teaching others about the care of dying residents and their families. For each question, rank your skills on a scale of 0 to 10, where 0 is not at all effective and 10 is very effective. 1. Communication with terminally ill residents and their families. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 2. Assessment/observation of common end-of-life symptoms such as pain, dyspnea, and anxiety. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 3. Pharmacologic management of common end-of-life symptoms such as pain, dyspnea, and anxiety. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 4. Nonpharmacologic management of common end-of-life symptoms such as pain, dyspnea, and anxiety. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 5. Discussion of goals of care with residents, families and other team members. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 6. Discussing and honoring spiritual practices at the end of life. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 7. Providing emotional support to residents and families at the end of life. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 8. Caring for residents from diverse cultural groups at the end of life. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 9. Educating residents, families, and other staff about the dying process. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 10. Understanding the role of hospice in the care of terminally ill residents and families. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 11. Collaborating with other health care team members to provide effective end-of-life care. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 12. Addressing legal and ethical issues at the end of life. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 13. Understanding and communicating the role of the nursing assistant in end-of-life care. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 14. Understanding and communicating the processes of grief and bereavement. Not at all effective Very effective 0 1 2 3 4 5 6 7 8 9 10 Thank you! You have reached the end of the questionnaire. Please read the statement below, and then click the Submit button to send your information. By clicking the Submit Feedback button below, I verify that, to the best of my knowledge, all information I have provided is accurate.