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1. Indicate your background: Nurse   Administrator   Dietitian   Other: 2. Indicate how you used the curriculum: One Component Two Components More than Two Components 3. How long was your in-service program? 30 minutes One hour More than one hour 4. This curriculum was easy to use: Strongly agree Agree Strongly Disagree Disagree No Opinion 5. Comments or Suggestions: If you would like additional information, please complete the following: Name: Organization: Street Address: City: State: New Jersey Delaware New York Pennsylvania Alabama Alaska Arizona Arkansas California Colorado Connecticut Dist. of Col. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Fed. States Micronesia Guam Marshall Islands North Mariana Is. Puerto Rico Virgin Islands Other (Use Address Line) Zip: +4: (optional) E-mail: Phone Number: ( ) -