Exercise Feedback Form

Form Approved

OMB No. 0920-0879

Exp. Date 02/18/2018

INSTRUCTIONS (Appendix C)

Exercise Participant Feedback Form is a voluntary assessment that is designed to be printed and distributed after the exercise to participants for their individual feedback on the exercise. Exercise facilitators / planners, please collect all completed forms, scan and submit to 2016CDCVIP@cdc.gov by 9/15/2016. All collected data will be shared in aggregate during the HHS Region VI VTTX Follow-up Meeting on Sept 29, 2016. It is estimated that completion of this assessment will take no longer than 10 minutes.

***Please note that question #4 needs to be edited to reference your state’s specific plan before distribution to participants.

EXERCISE PARTICIPANT FEEDBACK FORM (Appendix B)

1. Please rate, on a scale of 1 to 5, your overall assessment of the exercise relative to the statements provided below, with 1 indicating strong disagreement with the statement and 5 indicating strong agreement.

Assessment Factor	Strongly Disagree			Strongly Agree
The exercise was well structured and organized.	1	2	3		4	5
The exercise scenario was plausible and realistic.	1	2	3		4	5
The multimedia presentation helped the participants understand and become engaged in the scenario.	1	2	3		4	5
The facilitator(s) was knowledgeable about the material, kept the exercise on target, and was sensitive to group dynamics.	1	2	3		4	5
The Situation Manual used during the exercise was a valuable tool throughout the exercise.	1	2	3		4	5
Participation in the exercise was appropriate for someone in my position.	1	2	3		4	5
The participants included the right people in terms of level and mix of disciplines.	1	2	3		4	5

2. What organization are you representing in the exercise?

____________________________________________________________________

3. How many virtual exercises have you participated in before today’s exercise?

Zero	One to Two	Three or More

4. How familiar are you with [Insert Specific State] Plan?

Barely Familiar	Somewhat Familiar	Well Versed	Helped Write It

5. What specific training opportunities helped you (or could have helped you) prepare for this exercise? Please provide specific course names if applicable.

   Training	Completed Prior to Exercise? (Y/N)
   To be filled in	To be filled in
   To be filled in	To be filled in
   To be filled in	To be filled in
   To be filled in	To be filled in
   To be filled in	To be filled in

6. Which exercise materials were most useful? Please identify any additional materials or resources that would be useful.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Please provide any recommendations on how this exercise or future exercises could be improved or enhanced.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1050).