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

Profession

How many credit hours did you complete?

Credit Hours (maximum: 19.5)

Agreement

By completing this form, you attest that you have attended the number of hours you have indicated above.

I agree

To receive MOC hours, you must provide the information below. If you do not provide the information, your hours will not be reported to the board.

Learner ID# - example, 123456. If you do not know your board ID, you will need to contact your board for this information.

DOB (MM/DD) - For example, September 24 would be 09/24

Was the educational content of value to you?

Very Valuable

Somewhat Valuable

Not at all Valuable

Was the educational content scientifically sound?

If no, Tell us how...

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

If yes, what...

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

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

How do you think what you learned will benefit you in your practice?

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

Please suggest any areas of need, gaps in practice, and/or topics that you would like to see addressed in future educational activities.

Did you find any speakers to be exceptional?

Did you find any presentations to be exceptional?

Other comments or suggestions for improving this activity so that it will become more effective.