This document outlines a short self-completion questionnaire to evaluate a program. The questionnaire contains 4 sections: [1] questions about past use of the program, [2] a 5-point rating scale to rate different aspects of the program, [3] questions about the extent to which the program achieves key performance indicators using a scale, and [4] an open comment section. It concludes with a demographics section to collect information about attributes of respondents. The questionnaire is designed to collect both quantitative and qualitative feedback to evaluate the program.