Intervention Feedback, Assessment 4
1
Intervention Feedback Form
Assessment 4
Note: Please include this feedback in your capstone video.
You do not have to submit the completed feedback form; it’s simply a guide to help you capture
patient, family, or group feedback about your intervention.
1. Meeting date(s).
2. Length of the meeting(s) (in hours).
3. Location(s) of the meeting(s).
4. Describe the problem you were addressing.
5. Why was this a problem for the patient, family, or group?
6. What was your intervention?
7. How will the patient, family, or group apply the intervention?
8. How often will the intervention be used and under what circumstances?
9. How easy was it for the patient, family, or group to use the intervention?
10. Describe any challenges associated with the patient, family, or group’s use of the
intervention.
11. Were instructions necessary?
12. What did the patient, family, or group say about using the intervention?
13. Was the intervention helpful?
14. How will the patient, family, or group continue to use the intervention?
15. Explain how the intervention positively or negatively affected the patient, family, or
group’s life.
16. How can the effect be measured?
17. Update the total number of hours on the NURS-FPX4900 Volunteer Experience Form in
CORE ELMS.
- Intervention Feedback Form
- Assessment 4
