Breathing Space Kit Evaluation Form 2010

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Breathing Space Kit Evaluation 2010

Optional Contact Details:

Name:	Org:		Date:
Phone:	Fax:		Email:
Do you smoke tobacco?		Yes	No

1. Where did you hear about Breathing Space?

2. Have you used Breathing Space Kit?

	Yes	No, Please Comment (go to Q.3)

2a. Did you run the 6 week cessation program?
	Yes	No (go to Q.4)

3. On a scale of 1 to 5, where 1 is very successful and 5 is not at all successful. How much did you like the following aspects of the program?

4. What do you think about the length of the sessions (i.e. 2hrs)?

Too long

Just Right

Too short

5. What do you think about the number of sessions?

Too few

Just Right

Too many

6. What did you like best about this Kit?

7. What could we improve in this Kit? (did not like)

8. Who was in your Group?

Number of people:			Males		Females		Mixed
Age:

9. Did you use any part of the Breathing Space Kit as brief interventions with Participants?

	Yes, Which Part?		No

10. Were your Participants:

Voluntary

Involuntary

Staff

11. How successful was your cessation group? What percentage of your participants:

Quit during the program	%	Quit before the program	%
Have cut down significantly	%	Have cut down slightly	%
Smoking the same as before	%	Smoking more than before	%

12. What percentage of your participants attended?

All 6 sessions	%	5 sessions	%
4 sessions	%	3 sessions	%
2 sessions	%	1 session	%

13. How did you promote your cessation group to your target clientel?

14. Any other comments?

	Advertising		Website		Presentation		Interagency
	Workshop		Launch

3a. Overall program
1	2	3	4	5
3b. Program materials (handouts, powerpoints)
1	2	3	4	5
3c. Group discussions
1	2	3	4	5
3d. Activities
1	2	3	4	5