Required Questions

The evaluation must be emailed to the CME department for approval at least two (2) weeks before the activity start date. 

QUESTION 1

This activity was balanced and free of commercial bias.

1. Yes
2. No   Comments:                                                                                                

QUESTION 2

QUESTION 3: This educational activity will result in a change in my: (Mark all that apply) 

• Knowledge (facts and information acquired by a person through experience or education)
• Competence (having the ability to apply knowledge, skills, or judgment in practice if called upon to do so)
• Performance (what the participant does in practice)
• Patient outcomes (actual outcomes in individual patients and/or patient populations)
• Community (change in population health status) 
• This activity did not result in a change.

QUESTION 4: Describe any ‘pearls’ or takeaway messages. 

QUESTION 5: Note any changes or improvements in the care of your patients that you plan to make as a result of attending this educational activity. If no changes are identified, please explain why (program format, content not appropriate, nothing learned, etc.).

QUESTION 6: Identify any barriers that you perceive in implementing these changes. Mark all that apply.

DMU note: You can change, add, or delete the barriers below. An open text box is also sufficient. 

• No barriers
• Cost
• Lack of experience         
• Lack of opportunity/patients     
• Lack of resources/equipment
• Lack of administrative support   
• Insurance/reimbursement issues
• Lack of consensus or professional guidelines 
• Lack of time to assess/counsel patients
• Patient compliance issues           
• Not applicable to my practice         
• Other:

QUESTION 7: How will you address these barriers to implementing these changes in your practice? 

QUESTION 8: Given the scope of your practice, what educational needs do you have?

QUESTION 9: Please provide any additional comments and/or suggestions below.