The Great Escape Form

Report Form and Evaluation

School Name:
Grade Level:
County:
Number of students in your class:
Number of students who completed escape plan:
1. Did you present a lesson in conjunction with the video? Yes No
2. Did you show the video? Yes No
3. What did you think of the educational value of the video? Excellent Good Fair
4. How many of your students reported that they had already planned a home escape with their families? # students didn’t ask don’t know
5. Will you use this program with your classes in the future? Yes No
6. Do you have any comments or suggestions regarding the educational materials provided by the Burn Prevention Foundation?

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Mission Statement

The mission of the Burn Prevention Foundation is to provide burn injury prevention education to and advocacy for those at greatest risk. Our primary service area is in Eastern Pennsylvania, although many of our programs and products are utilized worldwide.