This questionnaire will attempt to assess the impact of the
"Non-violent physical intervention program" on participants.
Please circle the correct response to each item.  Please
return by XXXXXXX.. Thank you !!

A.  Thinking back, please select your appropriate response
to the following statements.

Superior    Excellent     Good    Fair    Poor
      5             4                3         2         1

1. relevance of topics to you              5 4 3 2 1
2. quality of teaching material             5 4 3 2 1
3. facilitator's knowledge of subject    5 4 3 2 1
4. facilitator's preparation                   5 4 3 2 1
5. activities and role plays                  5 4 3 2 1

B. Since my participation in CPI training: ....

Strongly Agree(SA)   Agree(A)  Neither(N)  Disagree(D) Strongly Disagree(SD)

6. I am confident in dealing with disruptive behaviors.
    SA A N D SD
7. Safety of contacts has improved.
    SA A N D SD
8. Disruptive incidents have been reduced.
    SA A N D SD
9. I prepare for safety in familiar and unfamiliar settings.
    SA A N D SD
10. I share recognition techniques and safety tips with others.
    SA A N D SD
 

C.  Please circle appropriate response for "before and after questions".

Since my participation in the non-violent physical intervention training, how many....

11. ...crisis situations have you been able to recognize?

BEFORE TRAINING EXPERIENCE:
none   1-3   4-6   7-8   over 8

AFTER TRAINING EXPERIENCE:
none   1-3   4-6   7-8   over 8

12. ...situations have escalated to a verbally acting out
person (AOP)?

BEFORE TRAINING EXPERIENCE:
none   1-3   4-6   7-8   over 8

AFTER TRAINING EXPERIENCE:
none   1-3   4-6   7-8   over 8
 

13. ...situations have escalated to a physically acting out
person (AOP)?

BEFORE TRAINING EXPERIENCE:
none   1-3   4-6   7-8   over 8

AFTER TRAINING EXPERIENCE:
none   1-3   4-6   7-8   over 8
 

D.  Approximately how often do you:

 Daily  Weekly  2x a month  Monthly   Less
   5          4              3              2            1
 

14. refer to the CPI notebook ?               5 4 3 2 1
15. recognize safe room set-up ?             5 4 3 2 1
16. use safety tips from workshop ?         5 4 3 2 1
17. use supportive stance ?                      5 4 3 2 1
18. recognize crisis behavior levels  ?       5 4 3 2 1
19. recognize kinesics (body language) ?  5 4 3 2 1
20. recognize non-verbal cues ?               5 4 3 2 1
21. become a "team leader" ?                   5 4 3 2 1
22. use non-violent physical intervention ? 5 4 3 2 1

23. Please describe your CPI experience in two words.
   ___________ , __________.
Other comments:
________________________________________________________
____________________________________________________________
_ __________.
THANK YOU FOR YOUR PARTICIPATION.  PLEASE MAIL OR FAX TODAY!!

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View Evaluative Report of the CPI Program