TRAINING PROGRAM EVALUATION FORM

For completion by training participants.

Be sure to complete any additional evaluation required by your residency or training program.

Name: _______________________________      Training Program: ________________________
Program Year: __________________________      Date:   ________________________________

 

  1. Please evaluate the following aspects of your rotation training experience by circling the appropriate response:
Poor Satisfactory Good Excellent Outstanding Did not experience
a Didactic teaching 1 2 3 4 5 N/A
b Syllabus 1 2 3 4 5 N/A
c Clinic orientation 1 2 3 4 5 N/A
d Abortion counseling experience 1 2 3 4 5 N/A
e Medical screening/management 1 2 3 4 5 N/A
f Pelvic examination / sizing 1 2 3 4 5 N/A
g Pain management techniques. 1 2 3 4 5 N/A
h Vacuum aspiration technique 1 2 3 4 5 N/A
i Use of ultrasound 1 2 3 4 5 N/A
j Routine post-abortion care 1 2 3 4 5 N/A
k Opportunities to ask questions 1 2 3 4 5 N/A
l Opportunities to interact with clinic staff 1 2 3 4 5 N/A
m Initial Program Orientation (didactic session at residency or professional training program) 1 2 3 4 5 N/A
  1. What did you like most about the training?

 

  1. What did you like least about the training?

 

  1. In your opinion, the length of your training was:

[ ] adequate

[ ] too short

[ ] too long

  1. Did the abortion training rotation adequately prepare you to:
a Counsel patients about pregnancy options Yes No, need more
b Counsel patients choosing abortion Yes No, need more
c Counsel patients about contraceptive options Yes No, need more
d Obtain informed consent for abortion Yes No, need more
e Perform accurate pelvic sizing Yes No, need more
f Perform aspiration procedures under local anesthesia Yes No, need more
g Perform 1st trimester aspiration abortions with confidence Yes No, need more
h Manage common abortion complications Yes No, need more
i Integrate abortion with other health services in your regular practice Yes No, need more
  1. What additional abortion training opportunities would you like your residency or training program to provide, if any?

 

  1. Please evaluate the following training faculty by circling the appropriate responses:

 

 Name of Trainer Poor Satisfactory Good Excellent Outstanding Did not
experience
1 2 3 4       5 NA
1 2 3 4       5 NA
1 2 3 4       5 NA
1 2 3 4       5 NA
1 2 3 4       5 NA
1 2 3 4       5 NA
Other: 1 2 3 4       5 NA

 

  1. What are your immediate career plans following graduation from this training program?

 

 

 

  1. What are your long-term career plans?

 

 

 

  1. Where do you hope to practice after graduating?

[ ]  In this state

[ ]  In another US state (specify: __________________)

[ ] Outside the US (specify: _________________)

[ ] Don’t know yet

  1. Do you plan to pursue additional abortion training during or after your residency or training program?

[ ] Yes    [ ] No    [ ] Undecided
If “Yes,” what additional training? ___________________________________

  1. Do you anticipate providing aspiration abortions in your post-graduate practice?

[ ] Yes    [ ] No    [ ] Undecided

  1. Do you anticipate providing early medication abortions (mifepristone or methotrexate) in your post-graduate practice?

[ ] Yes    [ ] No    [ ] Undecided

  1. Since completing the abortion training rotation, has your interest in or commitment to providing abortion services:

[ ]  Increased    [ ]  Decreased    [ ]  Remained the same

  1. Has the abortion training rotation influenced your attitudes or opinions about abortion in any positive or negative way? Please explain:

 

 

  1. What suggestions do you have for improving the training program?

 

 

  1. Other comments:

 

 

 

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