Required Questions

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

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

Question 1

This activity was balanced and free of commercial bias.

  1. Yes
  2. No   Comments: ​​​​​​​                                                                                               

Question 2

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

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.