Day 3 Forms Upload, Evaluation Form & DN-2 Certificate
Please note : The way you write your name, credentials, City, State etc.. in this form, the same way it will be printed on the certificate.
Name As You Want On Your Certificate (For credentials, please use only to max 2, so that the Certificate doesn't get distorted). (Also please add MDNc after the final credential)
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First Name
Last Name
Credentials
Email
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example@example.com
SEMINAR LEVEL ?
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MASTER DRY NEEDLING LEVEL-2
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Today's Date (Please put the last date of the seminar)
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-
Month
-
Day
Year
Date
SEMINAR City, State Of Seminar (Please write in the format as example - Raleigh, NC)
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example - Raleigh, NC
Instructor Name :
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Ken Cooper
Peter Friesen
Jared Estock
LICENSE NUMBER (S) & STATE(S)
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How would you rate this Seminar (1 star - sucks, 5 stars - Awesome)
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1
2
3
4
5
EVALUATION FORM
YOUR OVERALL SATISFACTION WITH THE COURSE (1 POOR, 5 EXCELLENT)?
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5
4
3
2
1
CURRENT LEVEL OF CONFIDENCE YOU NOW HAVE OF DRY NEEDLING (1 POOR, 5 EXCELLENT)?
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5
4
3
2
1
ABILITY YOU HAVE TO BEGIN INTRODUCING NEEDLING MONDAY (1 POOR, 5 EXCELLENT)?
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5
4
3
2
1
CONFIDENCE IN RECOMMENDING THIS COURSE TO OTHERS (1 POOR, 5 EXCELLENT)?
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5
4
3
2
1
THE INFORMATION RECEIVED WAS USEFUL AND BENEFICIAL
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE PROGRAM MET THE STATED LEARNING OBJECTIVES
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE PRESENTATION STYLE ENHANCED MY LEARNING EXPERIENCE
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE PROGRAM FACULTY WAS RESPONSIVE TO QUESTIONS/COMMENTS
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE EDUCATIONAL MATERIALS WERE USEFUL?
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE LEARNING ASSESSMENT (TEST) WAS APPROPRIATE
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
WHAT DID YO LIKE MOST ABOUT THIS PROGRAM?
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WHAT DID YO LIKE LEAST ABOUT THIS PROGRAM?
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DO YOU FEEL THERE WAS COMMERCIAL BIASE OR INFLUENCE IN THIS ACTIVITY?
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YES
NO
IF YES, PLEASE EXPLAIN
PLEASE RATE THE FOLLOWING COMPONENTS OF THIS PROGRAM
REGISTRATION PROCESS
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EXCELLENT
GOOD
FAIR
POOR
PROGRAM FACULTY
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EXCELLENT
GOOD
FAIR
POOR
LOCATION
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EXCELLENT
GOOD
FAIR
POOR
WAS THE PROGRAM FACULTY KNOWLEDGEABLE REGARDING THE CONTENT OF THEIR PRESENTATION
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YES
NO
WAS THE PROGRAM FACULTY RELEVANT REGARDING THE CONTENT OF THEIR PRESENTATION
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YES
NO
WAS THE PROGRAM FACULTY EFFECTIVE WITH THE CONTENT OF THEIR PRESENTATION
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YES
NO
IF YOU ANSWERED NO TO ANY OF THE 3 QUESTIONS ABOVE PLEASE EXPLAIN
THE PRESENTATION MET MY EXPECTATIONS
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE PROGRAM FACULTY STYLE WAS APPROPRIATE FOR THE MATERIAL PRESENTED
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE PROGRAM FACULTY WAS RESPONSIVE TO QUESTIONS/COMMENTS
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE PROGRAM MET MY OBJECTIVES
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
THE INFORMATION RECEIVED WAS USEFUL AND BENEFICIAL
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STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
GENERAL COMMENTS
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