Event data collection form for event organizers

Advance Care Planning (ACP) in Canada Initiative

Presenting Organization Name:*

Date of Event:*

Region Event Where Event Held:*

Names of Individual Presenter(s):*

Event Name (if applicable):

Format of Presentation:*

(e.g.: workshop, seminar, conference presentation, webinar, etc.)

Additional Resources Used at Event:

Language(s) of Presentation:*

Target Audience for Event:*

(Choose all that apply)

Number of attendees*

The UWIAB had all the information I needed to organize the workshop:

Resources provided by the UWIAB were useful

Training and/or explanations provided allowed me to easily implement the UWIAB:

Additional Comments

Would you be willing to allow the workshop organizers and ACP to contact you at a later date for a brief survey on the impacts of our tools and training sessions? If so, please provide your contact information below:

Name

First Last

Phone

Email

Name

This field is for validation purposes and should be left unchanged.

Universal Workshop in a Box Organizers Evaluation