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

Profession

What activities did you attend at the event?

Friday, 8:30 - 9:30 am

Friday, 9:30-10:00 am

Friday, 10:15-11:15 am

Friday, 11:15 - 11:45 am

Friday, 12:45-1:45 pm

Friday, 1:45-3:15 pm

Friday, 3:15-3:30 pm

Friday, 3:30-3:45 pm

Saturday, 8:15-9:15 am

Saturday, 9:15-9:45 am

Saturday, 10:00-10:30 pm

Saturday, 10:30-11:30 am

Saturday, 12:30-2:00 pm

Saturday, 2:15-02:30 pm

Saturday, 2:30-02:45 pm

Saturday, 2:45-03:00 pm

Saturday, 3:00-03:15 pm

Saturday, 3:15-03:30 pm

Saturday, 3:45-4:00 pm

Saturday, 4:00-4:15 pm

Sunday, 8:15-9:15 am

Sunday, 9:15-10:45 pm

Sunday, 11:00-11:15 am

Sunday, 11:15-11:30 am

Sunday, 11:30-12:30 am

Agreement

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

I agree

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?

Please tell us about any session you found particularly good or bad.

Please tell us about any objective you feel we accomplished well or poorly.

Please tell us about any presenter you found particularly good or bad.

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?

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

What questions have arisen in your practice for which you need answers/strategies that you can implement?

What patient/client problems or patient/client challenges do you feel you are not able to address appropriately or to your satisfaction?

What problems are your patients/clients communicating to you that need attention or follow up?

Are you interested in basic, intermediate or advanced level trainings?

Basic

Intermediate

Advanced

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: