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Posted November 2005

Smoke-free Campus Initiative
Tool Kit Evaluation Form

The Metropolitan Chicago Healthcare Council has embarked on this campaign on behalf of its members. Only through your valuable input and feedback can we work together to continue providing resources that best meets your needs.

Please take a few moments to complete the following survey and return it to the MCHC via fax to Gary Drain, human resource services, at 312-993-0779.

The evaluation form is also available online at www.mchc.org, in the members-only “Smoke-free Campus Initiative” section.

Thank you in advance for your assistance.

1. Overall, how would you rate the usefulness of this tool kit?

2. The tool kit is a valuable resource.

3. The contents of the tool kit are appropriate.

4. The tool kit included the right amount of information to communicate to various audiences on the issue.

5. Of all the materials included, which one did you find to be the most useful?

1. Guide to Successful Implementation
2. Sample Implementation Timeline
3. Sample Human Resources Policy
4. Frequently Asked Questions (FAQs)
5. Recommendations for Communications Tools
6. Smoke-free Resources and References
7. Case studies from Smoke-free Hospitals

6. Please describe in detail your use of these materials, including the audiences targeted (i.e., staff, media, public).

7. MCHC staff are available to meet with hospitals to discuss this campaign. Would you be interested in such a meeting?

_____Yes _____No

8. If yes, do you prefer meetings held in your area, with other hospitals participating, or held at the MCHC offices (222 S. Riverside Plaza, Chicago)?

_____In My Area _____MCHC Offices/Chicago

9. MCHC should continue providing tool kits on other topics.

_____Yes _____No

10. What topics are of interest to your institution?

11. Feel free to provide additional comments.

Contact information (optional):

name: _________________________ institution: __________________________

e-mail: _________________________ telephone: __________________________

If you have any questions about the Smoke-Free Campus Initiative or the tool kit materials, please feel free to contact Gary L. Drain, Human Resources, at 312-906-6026 or Liz Leonard, Public Affairs, at 312-906-6142.

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