Event Data Collection Form for Participants

Advance Care Planning in Canada Initiative

Name of Event:*

I am:*

Male
Female
Other

I am from (town/province):*

I am interested in ACP because of my role as (Select all the items that apply):*

Other :

Please help us evaluate this event and the tools presented

How likely are you to recommend this workshop?*

How clear were the objectives of this workshop?*

How would you rate the quality of tools provided (handouts, resources, etc)?*

How organized was the workshop?*

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.

UWIAB Participants Data Collection