1. When will you use these materials?
     Choose your answer First month received Within 3 months received Within the current year Not at all
    
2. Where are you most likely to use these materials?  (Check all that apply.)
   Worksite
   Hospitals/clinics
   Churches/Temples
   Businesses
   Schools
   Community-wide
   Statewide
   Radio/TV/Newspaper
   Other: 
    
3. Who is your target audience?  (Check all that apply.)
   Pregnant women
   Health care providers
   Groups at high risk for preterm birth
   General public
   Women of childbearing age
   Other audience: 
    
4. What are the most helpful components of the Toolkit?  (Check all that apply.)
   Introduction
   PowerPoint presentation
   Flip chart
   Fact Sheets
   Handouts (simplified versions of the fact sheets)
   Resources
   Tips for Success
   Activities
   Personal stories
   Contacts
   Spanish version
   Other: 
    
5. Please rate the level of helpfulness of the Toolkit to present the Preterm Birth message and additional information.
     Choose your answer Not helpful Somewhat helpful Moderately helpful Very helpful
    
6. Please rate your confidence in using the materials in the Toolkit.
     Choose your answer Not at all Very little Some Strong Very strong
    
7. How would you change the Toolkit to better assist you in presenting the Preterm Birth message?
   
    
8. Did you face any difficulties while conducting the activity?   No Yes
   If yes please explain: 
    
9. Do you have any additional comments?
   
    
10. What is your sex?    Female Male
     
11. What is your age?    Choose your answer 13-18 19-49 50-64 65+
     
12. Please select the highest level of education you have completed:    Choose your answer Some school High school Some college Undergraduate degree Graduate degree Higher than graduate degree
     

 Please click continue