Required Questions

Prior to distribution, the evaluation must be emailed to the CME department for approval at least two (2) weeks prior to the activity start date. 

Include the following statement: Evaluation results may be sent to the continuing education board. 

Question 1

Please indicate the extent to which you agree with the following statements:Strongly Agree (Yes)AgreeNeutralDisagreeStrongly Disagree (No)
The content is appropriate to my practice.     
This activity will make me more effective in my practice.     
This activity was balanced and free of commercial bias.     

Question 2 - FOR IN-PERSON ACTIVITIES ONLY (choose one)

Please rate the following: ExcellentVery GoodGoodFairPoor
Adequacy of facilities and resources.     
Overall administration of the activity.         
Quality of the speaker(s) instructional process and presentation including the effectiveness of educational methods.     
Speaker(s) teaching effectiveness, knowledge, and organization.     
Speaker(s) ability to communicate ideas and information clearly.     

Question 2 - FOR ONLINE ACTIVITIES ONLY (choose one)

Please rate the following: ExcellentVery GoodGoodFairPoor
Ease of use of the online platform.     
Overall administration of the activity.         
Quality of the speaker(s) instructional process and presentation including the effectiveness of educational methods.     
Speaker(s) teaching effectiveness, knowledge, and organization.     
Speaker(s) ability to communicate ideas and information clearly.     

Question 3

Did the activity meet your expectations in accomplishing the stated objectives?CompletelyMostlyPartiallyMinimallyNot at All
Objective 1     
Objective 2     
Objective 3     
Objective 4     

Question 4: 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 actually 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 5: Describe any ‘pearls’ or takeaway messages. 

Question 6: 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 7: Identify any barriers that you perceive in implementing these changes. Mark all that apply.

DMU note: You are able to 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 8: How will you address these barriers in order to implement these changes in your practice? 

Question 9: Given the scope of your practice, what educational needs do you have?