How would you like your name to appear on your certificate?

Profession

What activities did you attend at the event?

Schindler - 8:30 - 9:00

Kupfer - 9:00 - 9:30

Vignette - 9:30 - 9:45

Boden - 10:00 - 10:30

Harris - 10:30 - 11:00

Vignette - 11:00 - 11:15

Strate - 12:15 - 12:45

Strate - 12:45 - 1:15

Vignette - 1:30 - 1:45

Cote - 1:45 - 2:15

Fung - 2:15 - 2:45

Agreement

By completing this form, you attest that you have participated in all selected activities in thier entirety.

I agree

ABIM: If you do not provide your ABIM ID AND your DATE OF BIRTH, your hours will not be uploaded.

ABIM ID - Example 123456

Date of Birth (MM/DD) - Example September 24 would be 0924:

Was the educational content of value to you?

Very Valuable

Average

Not Valuable

Did you attend the session in its entirety?

Was the educational content scientifically sound?

Yes

No

If no, please explain...

Did you perceive any commercial bias or influence in the educational content?

Yes

No

If yes, please explain...

Did this program improve your Skill or Strategy in your role or contribution as a member of the healthcare team?

Yes

No

If no, why not?

Do you believe your participation in this activity will positively impact your healthcare team?

Yes

No

If yes, how?

If no, why not?

Tell us how well or poorly we met any of the educational objectives:

Do you think what you learned will benefit you in your practice?

Yes

No

If yes, how...

Tell us what was good or bad about any part of the educational activity, content, speakers, materials, anything:

What specifically did you learn during this activity that you intend to integrate into your practice?

What questions are you having in your practice that you would like to see addressed in an educational activity?

Additional comments: