Fresno County

							                                                                  Fresno County
                                                  Children’s Dental Disease Prevention Program
                                                              School Year 2005-2006
                                                               Teacher Evaluation


School                                                       Teacher                                                Grade


Thank you for participating in the Children’s Dental Disease Prevention Program this year. Because the program is
funded by the California Department of Health Services, it is required that an annual program evaluation be conducted.
Your feedback will also be considered to improve the program for next year. Your response and comments are greatly
appreciated. We hope it was a worthwhile and enjoyable experience for you and your students.

                                                                                                   Strongly                             Strongly
1.       Please rank your compliance with the following program components:                        Disagree                              Agree


         a) Average number of times per week brushing was performed:                                  0       1      2       3      4        5

         b) Average number of times per week fluoride tablet was performed:                           0       1      2       3      4        5

2.       If you were unable to follow through on all components of the program, what problems or difficulties
         prevented you from doing so?
                 □ Time                           □ No sink
                 □ Toothbrushing hygiene          □ Other __________________________________________

3.       Did you assist the students with their toothbrushing skills?                 □ Yes         □ No

4.       Did any of your students change their behavior as a result of this program?                      □Yes        □No

         If yes, please indicate how their behavior was changed (please mark one or more)

         □         Student formed a habit of toothbrushing
         □         Student went to the dentist
         □         Positive changes in student’s diet
         □         Other _________________________________________________________________________

5.       Do you feel that the in-class curriculum and/or Dental Health Fair presented was at the appropriate grade level
         for your class?                          □ Yes     □No
6.       Did the curriculum and/or Dental Health Fair assist you in meeting your Health Education Standards?
         □ Yes            □ No
7.       Overall, how would you rate the Children’s Dental Disease Prevention Program?
                                Excellent                      Satisfactory            Poor

          Additional comments:



8.       Do you plan to continue with the program next year?                  □ Yes       □ No

         Thank you for your time and input. Please return the evaluation and updated calendar to the office.
              Department of Community Health
              Education and Prevention Services
              Children’s Dental Programs
                                                                                              583e2def-4ac7-4ad0-9a9a-82d087c8bb6a.doc 07/29/12
              www.fresnohumanservices.org