Form Aaa-1194a Forpd - Ship Evaluation
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1AAA-1194A FORPD (2-10)
Arizona Department of Economic Security
Aging and Adult Administration
SHIP Evaluation
Program
Date
Please provide an honest assessment of this presentation session. As a participant, your
feedback is a valuable source of information and will help improve the quality of future trainings.
Strongly
Strongly
No
Use the following scale:
Agree
Neutral Disagree
Agree
Disagree
Opinion
Shade in one circle per question (example) ..........
Presenter/Method
1. The presenter was knowledgable....................
2. The presenter kept my interest........................
3. All my questions were answered.....................
Course Content
4. The information was easy to understand ........
5. The visual aids/handouts added to the
presentation.....................................................
Participant Benefits
6. The presentation met my expectations ...........
7. My knowledge of the subject has increased....
Participant Demographics
8. Age ..................................................................
Under 65
65 and over
9. Gender.............................................................
Male
Female
10. Education:
Up to 8th grade
HS grad/GED
Some college
College grad
11. Occupation before retiring:
Professional
Trade
Labor
Military
12. County of residence:
Apache
Cochise
Coconino
Gila
Graham
Greenlee
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
Equal Opportunity Employer/Program Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act
of 1975, the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race,
color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to allow a
person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department
must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print
materials. It also means that the Department will take any other reasonable action that allows you to take part in and
understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able
to understand or take part in a program or activity because of your disability, please let us know of your disability
needs in advance if at all possible. To request this document in alternative format or for further information about this policy,
call 602-542-4446; TTY/TDD Services: 7-1-1.
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