Screening and Brief Intervention Tool Kit for College and University Campuses DOT HS 810 751

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Appendix F

Evaluation Form

Please complete and fax to 303-871-0907 or mail to:
Ann Quinn-Zobeck, Ph.D.
The BACCHUS Network
PO Box 100430
Denver, CO 80250-0430

Thank you for participating in this program. Your feedback is important to us. Your honest opinion on the following questions about the program is greatly appreciated.

Circle the most appropriate number for your answer to each of the following statements

About the kit	Poor	Below Average	Average	Above Average	Excellent
1. Kit Contents	1	2	3	4	5
2. Organization of the kit	1	2	3	4	5
3. Handouts/resources	1	2	3	4	5
4. Overall Rrating	1	2	3	4	5
Reactions to the kit	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
5. The kit contents are easy to use to conduct screening and brief intervention sessions with students.	1	2	3	4	5
6. Using the kit increased my confidence in conducting screening and brief intervention sessions with students.	1	2	3	4	5
7. Overall, I felt that students who participated in a screening and brief intervention sessions responded positively to the information provided.	1	2	3	4	5
8. I plan to use the kit contents in the future with students.	1	2	3	4	5
9. What additional information would you like to see included in the kit.
10. Any additional comments about the kit?
General Information
Your position on campus
Prior experience with conduction alcohol screenings		None	Very little	Moderate	Extensive
Number of screenings and brief interventions you have conducted using this kit

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