My practice is primarily based in: *

Academics

Private practice

Hospital

Managed care

Research

Other

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

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

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

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Identify research findings that have implications for their practice in gerentology	Identify research findings that have implications for their practice in gerentology - Strongly Disagree	Identify research findings that have implications for their practice in gerentology - Disagree	Identify research findings that have implications for their practice in gerentology - Neutral	Identify research findings that have implications for their practice in gerentology - Agree	Identify research findings that have implications for their practice in gerentology - Strongly Agree
Integrate research from multiple disciplines to improve services for older patients	Integrate research from multiple disciplines to improve services for older patients - Strongly Disagree	Integrate research from multiple disciplines to improve services for older patients - Disagree	Integrate research from multiple disciplines to improve services for older patients - Neutral	Integrate research from multiple disciplines to improve services for older patients - Agree	Integrate research from multiple disciplines to improve services for older patients - Strongly Agree
Collaborate with colleagues from other disciplines to shape policy, care plans, and advocacy efforts based on the best available evidence	Collaborate with colleagues from other disciplines to shape policy, care plans, and advocacy efforts based on the best available evidence - Strongly Disagree	Collaborate with colleagues from other disciplines to shape policy, care plans, and advocacy efforts based on the best available evidence - Disagree	Collaborate with colleagues from other disciplines to shape policy, care plans, and advocacy efforts based on the best available evidence - Neutral	Collaborate with colleagues from other disciplines to shape policy, care plans, and advocacy efforts based on the best available evidence - Agree	Collaborate with colleagues from other disciplines to shape policy, care plans, and advocacy efforts based on the best available evidence - Strongly Agree
Incorporate new evidence into their professional practice	Incorporate new evidence into their professional practice - Strongly Disagree	Incorporate new evidence into their professional practice - Disagree	Incorporate new evidence into their professional practice - Neutral	Incorporate new evidence into their professional practice - Agree	Incorporate new evidence into their professional practice - Strongly Agree

Please rate your level of agreement with the following statements: *

	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 my practice	This activity was relevant my practice - Strongly Disagree	This activity was relevant my practice - Disagree	This activity was relevant my practice - Neutral	This activity was relevant my practice - Agree	This activity was relevant 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	The presentation was scientifically sound and free of commercial bias or influence - Strongly Disagree	The presentation was scientifically sound and free of commercial bias or influence - Disagree	The presentation was scientifically sound and free of commercial bias or influence - Neutral	The presentation was scientifically sound and free of commercial bias or influence - Agree	The presentation was scientifically sound and free of commercial bias or influence - 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 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

My current practice is consistent with the information presented

This topic is not within my scope of practice

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