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ECHO Health Programs
Facilitator and DVD User Feedback Form

Please take a few minutes to give us feed back on the
ECHO DVD and discussion guide.
Program viewed:

Language viewed:
Total number of participants who viewed the program:
Type of facility/location:

Community Program
Health Fair
Family/Home Use

Name of Location:
Sponsoring Agency:

Phone Number:

What went well? Highlights of the session?
     Problems encountered, if any:
Suggestions for ways to improve future ECHO DVD and discussion presentations:
Other comments:
How useful was the DVD?
How useful was the discussion guide?
How did you order the DVD?
Did you receive the DVD within 10-14 days after you requested it?
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