Practice Delivery Results Form

Please complete and submit this form following completion of your Practice Delivery Session. Following a review of the information provided, your Certificate of Completion and Program Delivery License will be sent to you electronically (usually within 72 hours).

First Name

Last Name

Title

Company

What was the age of the person with whom you practiced COPE?

How many trial sessions did you deliver?

What was the feedback from the student about the program?

Which of the sessions was most appealing to the student (please feel free to provide details)?

How did you, as the instructor, find delivery of the COPE program? Did you find reading directly from the student manual comfortable over time?

Which of the COPE sessions did you find most valuable (please feel free to provide details)?

How do you now intend to use COPE in your school or medical practice?

Other comments/Feedback/Questions

Practice Delivery Completion Date

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Practice Delivery Results Form