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

Profession

How many credit hours did you complete?

Credit Hours (maximum: 5.0)

Agreement

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

I agree

(MOC Credit Reporting) If you are claiming MOC points, please indicate the program(s) for upload. You can select more than one, if applicable.

(if you select a program not available for this activity, your points cannot be uploaded):

(MOC Credit Reporting) Please enter your Board Issued Learner ID. If you do not know your Board ID, you will need to contact your Board for this information. We cannot upload credits without a valid Learner ID.

Example: 525252:

(MOC Credit Reporting) Date of Birth - Month: Please select the number that represents the Month in which you were born (example: March is 03):

(MOC Credit Reporting) Date of Birth - Day: Please enter the day on which you were born (DD) -

For example, if you were born on the 6th, please enter 06:

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.