DN-1 Certificate & Day 3 Forms

Day 3 Forms Upload, Evaluation & DN-1 Certificate
Name As You Want On Your Certificate (Please fill all the boxes)*

First NameLast NameCredentials
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Date (Please put the last date of the seminar)*

MonthDayYear
Date
SEMINAR City, State Of Seminar (Please put the exact City & State - as this will be printed on your certificate)*
LICENSE NUMBER (S) & STATE(S) - (please fill in with your credentials)*
EVALUATION FORM
Name Of The Instructor :*

Ken CooperScott DixonSarah Austin & Lisa RigsbySarah AustinLisa RigsbyMitch HauschildtPeter Friesen
YOUR OVERALL SATISFACTION WITH THE COURSE (1 POOR, 5 EXCELLENT)?*

54321
CURRENT LEVEL OF CONFIDENCE YOU NOW HAVE OF DRY NEEDLING (1 POOR, 5 EXCELLENT)?*

54321
ABILITY YOU HAVE TO BEGIN INTRODUCING NEEDLING MONDAY (1 POOR, 5 EXCELLENT)?*

54321
CONFIDENCE IN RECOMMENDING THIS COURSE TO OTHERS (1 POOR, 5 EXCELLENT)?*

54321
THE INFORMATION RECEIVED WAS USEFUL AND BENEFICIAL*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE PROGRAM MET THE STATED LEARNING OBJECTIVES*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE PRESENTATION STYLE ENHANCED MY LEARNING EXPERIENCE*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE PROGRAM FACULTY WAS RESPONSIVE TO QUESTIONS/COMMENTS*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE EDUCATIONAL MATERIALS WERE USEFUL?*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE LEARNING ASSESSMENT (TEST) WAS APPROPRIATE*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
WHAT DID YO LIKE MOST ABOUT THIS PROGRAM?*
WHAT DID YO LIKE LEAST ABOUT THIS PROGRAM?*
DO YOU FEEL THERE WAS COMMERCIAL BIASE OR INFLUENCE IN THIS ACTIVITY?*

YESNO
IF YES, PLEASE EXPLAIN
PLEASE RATE THE FOLLOWING COMPONENTS OF THIS PROGRAM
REGISTRATION PROCESS*

EXCELLENTGOODFAIRPOOR
PROGRAM FACULTY*

EXCELLENTGOODFAIRPOOR
LOCATION*

EXCELLENTGOODFAIRPOOR
WAS THE PROGRAM FACULTY KNOWLEDGEABLE REGARDING THE CONTENT OF THEIR PRESENTATION*

YESNO
WAS THE PROGRAM FACULTY RELEVANT REGARDING THE CONTENT OF THEIR PRESENTATION*

YESNO
WAS THE PROGRAM FACULTY EFFECTIVE WITH THE CONTENT OF THEIR PRESENTATION*

YESNO
IF YOU ANSWERED NO TO ANY OF THE 3 QUESTIONS ABOVE PLEASE EXPLAIN
THE PRESENTATION MET MY EXPECTATIONS*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE PROGRAM FACULTY STYLE WAS APPROPRIATE FOR THE MATERIAL PRESENTED*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE PROGRAM FACULTY WAS RESPONSIVE TO QUESTIONS/COMMENTS*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE PROGRAM MET MY OBJECTIVES*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
THE INFORMATION RECEIVED WAS USEFUL AND BENEFICIAL*

STRONGLY AGREEAGREEDISAGREESTRONGLY DISAGREE
GENERAL COMMENTS
UPLOAD ALL DAY 3 FORMS by taking a picture on phone:
1. CHECKSHEET
2. TEST
3. PICS/VIDEOS NOT YET UPLOADED
UPLOAD HERE: TAKE PICS OF FORMS ON CAMERA. HIT BROWZE FILES AND THEN GO TO PHOTO GALLERY AND SELECT PICS OF FORMS FROM ABOVE.*

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Day 3 Forms Upload, Evaluation & DN-1 Certificate

EVALUATION FORM

PLEASE RATE THE FOLLOWING COMPONENTS OF THIS PROGRAM