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

Profession

Agreement

By completing this form, you attest that you have attended the activity in its entirety.

I agree

Please rate the following:

Please rate the speaker(s) as a group. You will have the opportunity to elaborate on an individual speaker in the following question.

If you have additional comments regarding the session or individual speaker(s) - e.g. teaching ability, expertise, organization of materials, etc. - please use the space below:

The program was relevant to my work.

Content matched stated objectives.

Usefulness of handouts/AV.

Quality of facilities.

If you rated any of the above questions with 'fair,' 'poor,' 'disagree,' or 'strongly disagree' please explain:

Please answer the following:

Do you believe this activity was appropriate for the scope of your professional activities?

Was the educational content scientifically sound?

Was the mode of education effective to learning?

If you answered "No" to any of the above questions, please explain.

How much did you learn as a result of this educational program?

Having completed the activity, please rate how well are you able to meet each of the following objectives

Placeholder

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

My professional performance would be improved if I had training on:

My patient outcomes would be improved if I had training on:

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 from this training?

How could this training be improved to impact your competence or performance in practice?

Additional comments: