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The North Carolina Asthma Plan Evaluation Form

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Thank you for taking time to read the North Carolina Asthma Plan. In order to help us evaluate the plan and improve future editions, please complete and submit the short online survey below. Your feedback will be sent to North Carolina Asthma Program staff.

Thank you in advance for your feedback.

The North Carolina Asthma Plan: Evaluation Form

The North Carolina Asthma Plan: Evaluation Form

If there is an asterisk "*" at the end of question, it means an answer is required. We ask that you complete questions 1-6. Questions 7, 8, and 9 are optional.

1. What type of organization do you represent (check all that apply): *

Local Health Department
State or Local Coalition
Community Health Organization
Hospital
Clinic or Medical Practice
Academic Institution (College, University)
Elementary/Secondary School
Medical/Health Professional Association
Faith Based Organization
Person with Asthma
Parent of Child with Asthma
OTHER

2. Name of organization (optional):

If you can see this field, please leave it blank.

3. What is your position in the organization (check all that apply): *

Physician
Nurse
Health Educator
Epidemiologist
Researcher
Faculty
Community Leader
Government Official
Legislator
Administrator
OTHER

4. How will you use this plan (check all that apply): *

Priority-Setting
Community-level Strategic Planning
Presentations
Grant Writing
Coalition Development
Educational Materials
OTHER

5. For each statement below, please select the choice that best reflects your opinion: *

a. This plan is clear and easy to understand.

b. This plan is well-organized.

c. The plan reflects the issues most important to addressing asthma in North Carolina.

d. The plan has helped me to structure and develop my asthma-related activities and interventions.

6. Please rate the usefulness of each section: *

a. The Executive Summary was:

b. Asthma is a Public Health Priority was:

c. The Burden of Asthma in North Carolina was:

d. The Planning Process was:

e. The Strategic Plan (by topic area):

e.1. Education and Public Awareness:

e.2. Health Disparities:

e.3. Medical Management:

e.4. Surveillance:

e.5. Environmental:

f. The Evaluation Plan was:

7. Please list any other content areas that you would like to see represented in future editions of the plan:

(You may enter up to 250 characters.)

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8. Please list any organizations (name, phone #, email address) you feel would benefit from this plan:

(You may enter up to 250 characters.)

Characters Remaining =

9. Other comments/suggestions:

(You may enter up to 250 characters.)

Characters Remaining =

To finish recommending the site, please complete the reCAPTCHA image verification challenge below (if displayed) and press the "Submit Evaluation" button.

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FAQs

Why are you being asked to complete the reCAPTCHA challenge? The reCAPTCHA, 3rd-party image verification tool helps identify the user as a human (rather than a spam-generating computer) and reduces the likelihood of this form being used for unintended purposes.

reCAPTCHA Quick Help:

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  • If you use the image-based challenge each word you type should be separated by a space.
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Where can I find more information? Visit Google's reCAPTCHA page.

Disclaimer: Use reCAPTCHA, a third-party tool, at your own risk. The Asthma Program has no control over the images/words displayed in the reCAPTCHA.

The Asthma Program does not monitor nor does it have any control over the reCAPTCHA service, apart from the inclusion of the service in this web page as a verification mechanism. The Asthma Program does not endorse or adhere to views or opinions expressed or perceived by any of the images/words in the reCAPTCHA tool. The Asthma Program does not endorse or adopt reCAPTCHA images/words and can make no guarantee as to their accuracy or completeness. The Asthma Program undertakes no responsibility to update or review any reCAPTCHA images/words.