Facilitator Evaluation for Prescription Opioid Toolkit

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Montana State University Extension

Prescription Opioid Education & Awareness Toolkit - Facilitator Evaluation

Program Location: _________________________________________________________________________________________

Date(s) & Time(s): _________________________________________________________________________________________

Your input and feedback are valuable to our education efforts. By completing this evaluation form, you are providing us with the necessary information to more effectively educate the public about opioids and the potential hazards associated with opioids. Thank you!

Audience Characteristics

Age:

Age group	Number of participants
Under 18
18 – 24
25 – 34
35 - 44
45 - 54
55 - 64
65+

Gender:

Gender	Number of participants
Female/Woman
Male/Man
Trans Male/Trans Man
Trans Female/Trans Woman
Gender Queer/Nonbinary
Another identity not listed above

Race/Ethnicity:

Race	Number of participants
Hispanic or Latino
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

Implementation Details and Feedback

Reason(s) for conducting this program (requested by a group/organization, open to the public): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Toolkit usage - please indicate the toolkit modules utilized:

Module 1: Introduction to Opioids
Module 2: Prescription Opioids & Home Safety: Proper Storage & Disposal
Module 3: Stigma & Opioid Use Disorder
Module 4: Prescription Opioid Use Disorder: Community Resources
Bonus Module: Opioid Use Disorder Treatment & Recovery Information

Ease of implementation – please rate whether or not the module(s) were “user-friendly”:

Extremely difficult
Somewhat difficult
Neutral
Somewhat “user-friendly”
Extremely “user-friendly”

Estimated time for completion:

Significantly underestimated (took far more time than anticipated)
About right (time to complete session(s) was accurately anticipated)
Significantly overestimated (took far less time than anticipated)

List any challenges or concerns associated with the implementation of these lessons:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Perception of audience reactions to the lesson(s):

Very negative
Negative
Neutral (or mixed)
Positive
Very positive

Perception of audience interest/engagement:

Extremely disinterested/disengaged
Disinterested/disengaged
Neutral (or mixed)
Interested/engaged
Extremely interested/engaged

Please list any challenges or concerns regarding audience reactions, questions/comments, or engagement: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Were there any portions of the module(s) that you omitted or modified? If so, please describe these changes and why you made them.

Did you present the lesson(s) yourself or did you use the pre-recorded slideshow(s)?

Presented myself
Used pre-recorded slideshow

Please indicate which of the following materials you utilized during your session(s). If you distributed any of these materials, please indicate that as well:

		Utilized	Distributed
Module 1
•	Common Names for Prescription Opioid Pain Medications	□	□
•	2021 CDC Drug Overdose Deaths, 2015-2020	□	□
•	MontGuide: Prescription Opioid Use and Misuse in Montana	□	□
Module 2
•	DPHHS – Addictive & Mental Disorders Division, Mental Health Services Bureau Programs & Contacts	□	□
•	Montana Standing Order for Naloxone Opioid Antagonists, Jan. 1, 2021	□	□
•	Montana Implementation Guide for Access to Naloxone Opioid Antagonists, May 2019	□	□
•	Montana Prescription Drug Drop Box Locations	□	□
•	Permanent Prescription Drug Drop Box Locations in Montana	□	□
•	Drug Disposal: FDA’s Flush List for Certain Medications	□	□
•	Prescription Drugs/Medications: Proper Use, Storage & Disposal	□	□
•	Website Links for the Proper Disposal of Prescription Medications	□	□
Module 3
•	MontGuide: Stigma Free Addictions Terminology for Montanans	□	□
Module 4
•	DPHHS – Addictive & Mental Disorders Division, Mental Health Services Bureau Programs & Contacts	□	□
•	Montana Standing Order for Naloxone Opioid Antagonists, Jan. 1, 2021	□	□
•	Montana Mental Health Centers Directory	□	□
•	Montana Implementation Guide for Access to Naloxone Opioid Antagonists, May 2019	□	□
•	Website Links for Community Resources	□	□
•	2021 CDC Drug Overdose Deaths, 2015-2020	□	□
•	MontGuide: Understanding and Finding Mental Health Providers	□	□
Bonus Module
•	2021 CDC Drug Overdose Deaths, 2015-2020	□	□

Additional Toolkit/Module Feedback:
Use the space below to provide additional feedback and/or suggestions to improve this module or toolkit.

Thank you for completing this evaluation form. Submit this form to Jennifer Munter, Program Manager by email (jennifermunter@montana.edu) or by mailing to: P.O. Box 173370, Bozeman, MT 59717-3370 (Attn: Jennifer Munter).

For more information about the MSU Extension Opioid Awareness & Education Program visit: http://health.msuextension.org/opioid_misuse.html or contact Barbara Allen, Project Director at: blallen@montana.edu.

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