[Insert Event Organizer / Logo]

Overall Evaluation

[Course Name:]

[Date:]

Instructions

Please complete this form at the end of your attendance at the course and return it to the registration desk.

A.Information about You:

1. Physician:☐Family Medicine☐Specialist☐Resident☐Other

Non-Physician:☐Nursing☐Other Specialty

2.Location:☐City☐Town☐Rural

3.Reasons for Attending:

☐Updating Knowledge☐Credits☐Topics☐Guest Speakers

4. OtherReasons:______

B.Overall Comments about this Conference:

(1 – Poor2 – Fair3 – Good4– Excellent)

(Circle your response)

Facilities:1234

Program:1234

Organization1234

About the [insert year] [program name]Program

(Circle your response)
Please rate the importance to you of the following aspects of the [course name] / NotImportant / ExtremelyImportant
Information gained through plenary presentations / 12345
Information obtained in interactive workshops / 12345
Raises questions that I will investigate later / 12345
Confirms that I am up-to-date in my clinical practices / 12345
Time spent with colleagues outside of sessions / 12345
Time spent with experts / 12345
Hands-on opportunities in Workshops / 12345
The aspects of the conference I liked best were:
Aspects of the conference that can be improved:

As a result of this presentation, I will make the following change(s) to my practice:

Please rate (circle) how well you think the format of this meeting works,ie. the number and balance of plenary and workshop sessions.

Does not work well / Worksextremely well
1 / 2 / 3 / 4 / 5

Are there changes or other educational formats (eg. informal discussion groups; hands on skill development) that you think we should try? Please be specific.

Please list ideas and topics for next year’s program. Add specific topic (could be case-based) and ask for specific aspect.

How did you hear about this conference?

☐CME website...... ☐Attended previous conference

☐Direct mailing...... ☐Word of mouth☐Email

Additional comments:

______

THANK YOU!

Page 1 of 3