Critical Incident Questionaire

Critical Incident Form

Thank you for participating in one of our programs, the Critical Incident Questionnaire
(CIQ) is a simple evaluation method that is used to discover what program participants
are learning. The CIQ allows participants to identify and comment on critical moments
during the program. The five questions are always the same and you may respond
anonymously.

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Program Name *

Program Date *

Name (optional)

Email Address (optional)

1. At what moment in the program did you feel most engaged with what was happening? *

2. At what moment in the program did you feel most distanced from what was happening? *

3. What action that anyone (presenter and participant) took this week did you find most affirming or helpful? *

4. What action that anyone (presenter and participant) took did you find most puzzling or confusing? *

5. What is it about the program that surprised you the most? (This could be about your own reactions to what went on, something someone did, or anything that occurred.) *

Additional questions and/or comments

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