Please rate the degree to which the following enhanced your learning experience: *

	Low	Below Avg	Avg	Above Avg	High
Faculty	Faculty - Low	Faculty - Below Avg	Faculty - Avg	Faculty - Above Avg	Faculty - High
Format	Format - Low	Format - Below Avg	Format - Avg	Format - Above Avg	Format - High
Program materials	Program materials - Low	Program materials - Below Avg	Program materials - Avg	Program materials - Above Avg	Program materials - High
Level of interaction	Level of interaction - Low	Level of interaction - Below Avg	Level of interaction - Avg	Level of interaction - Above Avg	Level of interaction - High

As a result of participating in this activity, I am better able to: *

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Learning Objective 1	Learning Objective 1 - Strongly Disagree	Learning Objective 1 - Disagree	Learning Objective 1 - Neutral	Learning Objective 1 - Agree	Learning Objective 1 - Strongly Agree
Learning Objective 2	Learning Objective 2 - Strongly Disagree	Learning Objective 2 - Disagree	Learning Objective 2 - Neutral	Learning Objective 2 - Agree	Learning Objective 2 - Strongly Agree
Learning Objective 3	Learning Objective 3 - Strongly Disagree	Learning Objective 3 - Disagree	Learning Objective 3 - Neutral	Learning Objective 3 - Agree	Learning Objective 3 - Strongly Agree
Learning Objective 4	Learning Objective 4 - Strongly Disagree	Learning Objective 4 - Disagree	Learning Objective 4 - Neutral	Learning Objective 4 - Agree	Learning Objective 4 - Strongly Agree
Learning Objective 5	Learning Objective 5 - Strongly Disagree	Learning Objective 5 - Disagree	Learning Objective 5 - Neutral	Learning Objective 5 - Agree	Learning Objective 5 - Strongly Agree

Please rate your level of agreement with the following: *

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
This activity met my educational needs, expectations, and objectives	This activity met my educational needs, expectations, and objectives - Strongly Disagree	This activity met my educational needs, expectations, and objectives - Disagree	This activity met my educational needs, expectations, and objectives - Neutral	This activity met my educational needs, expectations, and objectives - Agree	This activity met my educational needs, expectations, and objectives - Strongly Agree
This activity was relevant to my practice	This activity was relevant to my practice - Strongly Disagree	This activity was relevant to my practice - Disagree	This activity was relevant to my practice - Neutral	This activity was relevant to my practice - Agree	This activity was relevant to my practice - Strongly Agree
I feel confident treating patients in my practice based on this activity	I feel confident treating patients in my practice based on this activity - Strongly Disagree	I feel confident treating patients in my practice based on this activity - Disagree	I feel confident treating patients in my practice based on this activity - Neutral	I feel confident treating patients in my practice based on this activity - Agree	I feel confident treating patients in my practice based on this activity - Strongly Agree
This activity rates highly in comparison with other CE/CME activities in which I have participated in the last 12 months	This activity rates highly in comparison with other CE/CME activities in which I have participated in the last 12 months - Strongly Disagree	This activity rates highly in comparison with other CE/CME activities in which I have participated in the last 12 months - Disagree	This activity rates highly in comparison with other CE/CME activities in which I have participated in the last 12 months - Neutral	This activity rates highly in comparison with other CE/CME activities in which I have participated in the last 12 months - Agree	This activity rates highly in comparison with other CE/CME activities in which I have participated in the last 12 months - Strongly Agree
There is a continuing need for education on this topic	There is a continuing need for education on this topic - Strongly Disagree	There is a continuing need for education on this topic - Disagree	There is a continuing need for education on this topic - Neutral	There is a continuing need for education on this topic - Agree	There is a continuing need for education on this topic - Strongly Agree
The presentation was scientifically sound and free of commercial bias* or influence (*Commercial bias is defined as a personal judgement, not consistent with the best available clinical evidence, that favors a specific product or service of a commercial interest)	The presentation was scientifically sound and free of commercial bias* or influence (*Commercial bias is defined as a personal judgement, not consistent with the best available clinical evidence, that favors a specific product or service of a commercial interest) - Strongly Disagree	The presentation was scientifically sound and free of commercial bias* or influence (*Commercial bias is defined as a personal judgement, not consistent with the best available clinical evidence, that favors a specific product or service of a commercial interest) - Disagree	The presentation was scientifically sound and free of commercial bias* or influence (*Commercial bias is defined as a personal judgement, not consistent with the best available clinical evidence, that favors a specific product or service of a commercial interest) - Neutral	The presentation was scientifically sound and free of commercial bias* or influence (*Commercial bias is defined as a personal judgement, not consistent with the best available clinical evidence, that favors a specific product or service of a commercial interest) - Agree	The presentation was scientifically sound and free of commercial bias* or influence (*Commercial bias is defined as a personal judgement, not consistent with the best available clinical evidence, that favors a specific product or service of a commercial interest) - Strongly Agree

If you thought the presentations were commercially biased, please explain:

For you, was the educational level of this activity: *

Too basic

Appropriate

Too advanced

Of all of your patients that you see per month, how many are likely to be impacted by the information that you acquired in this CE/CME activity? (example:50) *

Based upon your participation in this activity, choose the statements that apply: (mark all that apply) *

I plan to implement new strategies/skills/information

I gained new strategies/skills/information that I can apply to my area of practice

I need more information before I can implement new strategies/skills/information

None, my current practice is consistent with the information presented

None, this topic is not within my scope of practice

None, I do not agree with the information presented

What, if any, additional changes do you plan to implement into your practice?

My confidence level in being able to implement these changes is: *

Very confident

Somewhat confident

Uncertain

Little confidence

No confidence

Not applicable

If you consider a change in practice, please check any barriers to overcome before initiating that change: *

Organizational constraints

Formulary issues

Patient reluctance to change

patient nonadherence

Insufficient time

Financial/Insurance

Do not know enough about the recommendations to change yet

What still remains unanswered for you?

Additional comments:

Leave this field blank