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

Profession

What activities did you attend at the event?

Saturday

Sunday

Agreement

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

I agree

(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:

Please rate the following:

The program was relevant to my work.

Content matched stated objectives.

Usefulness of handouts/AV/technology.

Quality of facilities/facility accomodations or website/accessibility if online.

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?

Objective 1: Update current clinical knowledge and processes to optimize clinical care for patients.

By meeting the above objective my professional competence will increase because I have acquired new strategies to use in my practice.

By meeting the above objective my professional performance will improve because I should be able to implement the new strategies.

By meeting the above objective my patient outcomes should improve due to the implementation of newly-learned strategies.

The teaching methods used were appropriate to the objectives

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

Yes

No

Please explain how, or why not?

Please answer the following:

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 commercial bias or influence in the educational content?

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 area (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):

Do you believe your participation in this activity will positively impact your healthcare team?

Yes

No

Why or why not?

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?

Additional comments: