1 Start 2 Complete

Expected Clinical Outcomes

Will you make any changes in your practice as a result of participating in this activity? *

Yes

No

N/A

If yes, what changes will you make? *

Will information gained from this program result in enhancing optimal patient care? *

Yes

No

If yes, please list change(s) you intend to make in your practice as a result of this program *

Please rate your confidence in implementing these changes *

High confidence

Moderate confidence

Low/no confidence

N/A

Please identify any barriers you perceive in implementing these changes (select all that apply) *

Cost

Lack of time to assess/counsel patients

Lack of administrative support/resources

Insurance/reimbursement issues

Patient compliance issues

Lack of consensus of professional guidelines

Other

N/A

How will you address these barriers to implement changes in knowledge and behavior? *

Basic Program Evaluation *

	Excellent	Above Average	Average	Below Average	Poor
The material was presented at an appropriate level	The material was presented at an appropriate level - Excellent	The material was presented at an appropriate level - Above Average	The material was presented at an appropriate level - Average	The material was presented at an appropriate level - Below Average	The material was presented at an appropriate level - Poor
I have gained knowledge that will improve patient care	I have gained knowledge that will improve patient care - Excellent	I have gained knowledge that will improve patient care - Above Average	I have gained knowledge that will improve patient care - Average	I have gained knowledge that will improve patient care - Below Average	I have gained knowledge that will improve patient care - Poor
The program met my expectations in accomplishing the stated educational objectives	The program met my expectations in accomplishing the stated educational objectives - Excellent	The program met my expectations in accomplishing the stated educational objectives - Above Average	The program met my expectations in accomplishing the stated educational objectives - Average	The program met my expectations in accomplishing the stated educational objectives - Below Average	The program met my expectations in accomplishing the stated educational objectives - Poor
The program content was objective, balanced, and free from commercial bias or influence	The program content was objective, balanced, and free from commercial bias or influence - Excellent	The program content was objective, balanced, and free from commercial bias or influence - Above Average	The program content was objective, balanced, and free from commercial bias or influence - Average	The program content was objective, balanced, and free from commercial bias or influence - Below Average	The program content was objective, balanced, and free from commercial bias or influence - Poor
Your overall rating of the quality of the education offered at this program	Your overall rating of the quality of the education offered at this program - Excellent	Your overall rating of the quality of the education offered at this program - Above Average	Your overall rating of the quality of the education offered at this program - Average	Your overall rating of the quality of the education offered at this program - Below Average	Your overall rating of the quality of the education offered at this program - Poor

How can this program be improved?

Additional Comments:

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