North Carolina Asthma Program: The Burden of Asthma in North Carolina Report Evaluation Form

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Datos Básicos sobre el Asma

Thank you for taking time to read the Burden of Asthma in North Carolina, 2006. In order to help us evaluate the report 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 Burden of Asthma in North Carolina Report: Evaluation Form

In order to complete this evaluation, you must have a Javascript-enabled browser. If a Javascript-enabled browser is not available to you, please download the PDF version of this form, complete, and return via fax to 919-870-4801. If you complete the PDF version using Adobe Reader, please be aware that form data cannot be saved to your local hard drive using Adobe Reader. If you require additional help submitting the form, please call 919-707-5210.)To enable Javascript:

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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, Practice, or Medical Facility
Academic Institution (College, University)
Elementary/Secondary School
Medical/Health Professional Association
Faith Based Organization
Person with Asthma
OTHER (Enter up to 40 characters.)

2. Name of organization: *

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 report (check all that apply): *

Grant-writing
Priority-setting/Planning/Targeting Programs
Educational Materials
Presentations
OTHER

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

a. This report is clear and easy to understand.

b. This report is well-organized.

c. This report has improved my understanding of Asthma in North Carolina.

d. This report will be useful to me in my work.

6. Please rate the usefulness of each section: *

a. The Executive Summary was:

b. The Introduction was:

c. The Asthma Prevalence section was:

d. The Asthma Management and Quality of Life section was:

e. The Health Care Utilization section was:

f. The Mortality section was:

g. The Healthy People 2010 section was:

h. The Discussion, References, and Technical Notes were:

i. The Appendices were:

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

(You may enter up to 250 characters.)

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

(You may enter up to 250 characters.)

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9. Other comments/questions/suggestions:

(You may enter up to 250 characters.)

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