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

Profession

How many credit hours did you complete?

Credit Hours (maximum: 10.5)

Agreement

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

I agree

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

Was the educational content of value to you?

Very Valuable

Somewhat Valuable

Not at all Valuable

Was the educational content scientifically sound?

Yes

No

If no, Tell us how...

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

Yes

No

If yes, what...

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, tell us how... Or if no, tell us why not...

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

Yes

No

If yes, how...

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

What questions are you having in your practice that you would like to see addressed in an 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 knowledge, strategies/skills, performance and/or patient outcomes?

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