Activity Evaluation Form:

Thank you for your participation in:

Title of Program

Date of program, Year

Location of Program, Icahn School of Medicine at Mount Sinai

All attendees are urged to complete an evaluation.

PLEASE KEEP THIS FORM SO YOU CAN COMPLETE THE EVALUATION ONLINE AT:

http://www.surveymonkey.com/s/xxxxxxx

Your comments are essential for improving the effectiveness of Icahn School of Medicine at Mount Sinai’s continuing medical education activities. Please complete this questionnaire and return it following the completion of the activity.

General Information
Degree(s): MD DO PA NP RN MSW Other ______
Specialty: Other______

For the following sections, please circle the appropriate response.

1.  Please indicate how well this activity addressed each of the following educational objectives:

Educational Objective
As a result of attending this activity, I am better able to: / Strongly Agree / Agree / Neutral / Disagree* / Strongly Disagree*
5 / 4 / 3 / 2 / 1
5 / 4 / 3 / 2 / 1
5 / 4 / 3 / 2 / 1
5 / 4 / 3 / 2 / 1

·  If any response is Disagree OR Strongly Disagree, please check all reasons that apply for disagreeing:

Cost / Reimbursement/Insurance issues
Further training is needed / Lack of staff or health system support
Not applicable to my practice / Lack of consensus or professional guidelines
Other, Please specify

2.  Please rate speakers using the following scale 5 = strongly agree and 1 = strongly disagree.

Speakers and Topics/Objectives

/ Speaker was an effective teacher / Topic was relevant to my practice / Session objectives were met / Topic was presented without bias

3.  Please respond to the statements below.

Activity Planning Quality / Strongly Agree / Agree / Neutral / Disagree / Strongly Disagree
I will recommend this activity to colleagues / 5 / 4 / 3 / 2 / 1
The overall activity met my expectations / 5 / 4 / 3 / 2 / 1
The activity materials were useful / 5 / 4 / 3 / 2 / 1
Physical facilities were useful to learning/conducive to learning format / 5 / 4 / 3 / 2 / 1
Course organization and registration were satisfactory / 5 / 4 / 3 / 2 / 1
Teaching format was appropriate to achieve program objectives / 5 / 4 / 3 / 2 / 1
This activity provided evidence-based information that will be useful to me in my job or practice / 5 / 4 / 3 / 2 / 1
As a result of information received today, I plan to make changes that will benefit patient care / 5 / 4 / 3 / 2 / 1
Projected impact of this activity / Strongly Agree / Agree / Neutral / Disagree / Strongly Disagree
This activity will increase my competence / 5 / 4 / 3 / 2 / 1
This activity will improve my performance / 5 / 4 / 3 / 2 / 1
This activity will improve my patient outcomes / 5 / 4 / 3 / 2 / 1

4.  If you will make changes to benefit patient care, please describe the changes that you will make:

5.  Which of the following competency areas do you feel have been improved as a result of this activity? (Check all that apply)

Patient care / Interpersonal and communication skills
Medical knowledge / Professionalism
Practice-based learning and improvement / System-based practice

6.  This activity was presented free from commercial bias1 in the educational content. Yes No

If no, what did you perceive? ______

1Defined as: information presented in a manner that attempts to sway participant’s opinions in favor of a particular commercial product or the express purpose of furthering a commercial entity’s business, meaning a deliberate intent to mislead. (The Journal of Continuing Education in the Health Professions, Volume 26, pp. 161-167.)

7.  This activity was scientifically rigorous and fair balanced. Yes No

If no, what did you perceive? ______

8.  In order for us to provide educational activities that meet your professional needs, the ACCME requires us to identify gaps in learning. What problems or issues in your practice would you like our continuing medical education program to try and help you with? Please list any topic or subject matter that should be included in future activities that would positively impact patient care, and/or improve clinical and non-clinical skills.

9.  Do you have any additional comments or suggestions for improving future courses?

10.  How did you hear about this course?

Internet Brochure Colleague Email Medical Journal Other

Thank you for taking the time to complete this evaluation form.

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