We've detected that Javascript is not enabled. It is required for an optimal survey taking experience.
Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript.

Skip survey header

Session Report Form

Page One

First and Last Name *This question is required.

Co-Presenter First and Last Name (if applicable)

Additional Co-Presenter First and Last Name (if applicable)

Session Date *This question is required.

Session Start Time *This question is required.

Length of Session (Please record to closest 15 minutes increments)

Prep/Travel Time if applicable (Record to closest 15 minute increments)

Audience

Church/Parish Group
Community Group
Other Please enter an 'other' value for this selection.

Number of Attendees

Presentation Type

Unit Presented

Advance Care Planning
Bone Health
Brain Health
Breast Cancer
Diabetes Prevention
Gynecologic Cancers
Heart Disease & Stroke
Journaling - Coping with Stress
Mental Health
Nutrition
Opioid Misuse Prevention
Self Care
Sleep

1. Did you feel your presentation/conversation flowed well? Were you comfortable with the process and materials?

2. Did the participants have any questions that were not addressed in the PowerPoint/script/facilitator's guide that you feel it would be helpful to add to either?

3. Did you feel you had adequate information to support your outreach education program/to organize and carry out the session?

4. Please share any suggestions or comments to improve the flow or material support of your women's health education outreach relative to GrapeVine.

5. What worked well? What additional support would you like in the future?

6. Do you have a photo(s) to submit from your session?

7. For any images that include GrapeVine participants, was their consent obtained (either verbally or in writing)? *This question is required.

7. Please upload your session photo(s). Submitting your photo automatically enters you into our monthly gift card drawing.
(Max Upload Size Per File: 25MB, Max Number of Files: 5)

File: {{filename}} delete