Evaluation Form
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This evaluation form is important in receiving feedback on both the speaker’s presentation and the presentation module.  Please use this form, which can be duplicated as needed, at every outreach event. It should be distributed to the audience prior to your lecture.  Make sure to leave time at the end of your program for the audience to complete the forms.

Please note: This form is designed to be filled out by adults.  For younger audiences, please provide the teacher/caregiver with the appropriate evaluation form to fill out. 

Evaluation Form

Send completed evaluation forms to:

Illinois Poison Center

 Education and Outreach Coordinator

222 S. Riverside Plaza

Suite 1900

Chicago, IL 60606

Fax to 312-627-8006

© 2007 Illinois Poison Center, a program of the Metropolitan Chicago Healthcare Council

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