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HCC - Sample UA
Mr pencil

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



What activities did you attend at the event?
Agreement
By completing this form, you attest that you have participated in all selected activities in thier entirety.
Learner ID# - example, 123456. If you do not know your board ID, you will need to contact your board for this information. (If applicable - excludes ABS.)
DOB (MM/DD) - For example, September 24 would be 09/24
Please rate the following:
The program was relevant to my work.
Content matched stated objectives.
Usefulness of handouts/AV/technology.
Quality of facilities.
How well did the educational sessions give a balanced view of therapeutic options, including the use of generic names?
If you rated any of the above questions with 'fair,' 'poor,' 'disagree,' or 'strongly disagree' please explain in detail (e.g. session title, speaker name, situation):
Did you attend the session in its entirety?
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Please rate the accuracy of this statement: The activity met the stated educational objectives.
Did this program improve your Skill or Strategy in your role or contribution as a member of the healthcare team?
Please explain how, or why not?
Please answer the following:
Do you believe this activity was appropriate for the scope of your professional activities?
Was the educational content scientifically sound?
If faculty spoke about off-label or investigational uses of a product, was that information disclosed to you?
Was the mode of education effective to learning?
If you answered "No" to any of the above questions, please explain.
Did you perceive any product/service/company/commercial bias in any educational session you attended or materials you received?
If you answered "Yes" to the above question, please detail the situation below (e.g. session title, speaker name):
Were you solicited by sales personnel in an educational room (other areas do not matter) while you attended this educational activity?
If you answered "Yes" to the above question, please explain in detail (e.g. who, when, where):
How much did you learn as a result of this education program?
Do you believe your participation in this activity will positively impact your healthcare team?
Why or why not?
What questions are you having in your practice that you would like to see addressed in a future educational activity?

What barriers might you have that would interfere with implementation of new information learned from this training?

How can this training (the overall meeting) be improved to better impact competence, performance and/or patient/client outcomes?

Additional comments:

Mr question
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