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CME FORM 108
PLEASE COMPLETE THIS EVALUATION SUMMARY AFTER EACH CME ACTIVITY AND SUBMIT IT WITH THE CME FORM 105 CLOSING REPORT TO THE UHMS HOME OFFICE CME COORDINATOR.
ENTER THE NUMBER OF TOTAL RESPONSES INDICATED. A PERCENTAGE MAY BE USED IF YOU PREFER
1.This session has increased, improved, or positively impacted my: (select all that apply)
O Knowledge______respondents
O Competence______respondents
O Performance______respondents
O Patient Outcomes______respondents
O No Change______respondents
2.This activity is free of commercial bias* or influence?
O Yes ______respondents
O No______respondents
If any respondents answered yes, please list comments for the Subcommittee on CME Effectiveness to review:
3.The overall objective was met
OYes______respondents
O No______respondents
4.This activity met my educational needs
O Yes______respondents
O No______respondents
5.The references were appropriate
O Yes______respondents
O No______respondents
6.The educational format(s) is appropriate for the setting, objective, and desired result
O Yes______respondents
O No______respondents
7.The content matches my current or potential scope of professional activities
O Yes______respondents
O No______respondents
8.This activity has addressed competencies that are applicable with the following: (select all that apply):
CME Form 108 Evaluation Summary
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O Patient care or patient-centered care______respondents
O Interpersonal and communication skills______respondents
O Practice-based learning & improvement______respondents
OProfessionalism______respondents
O System-based practice______respondents
O Interdisciplinary teams______respondents
O Quality improvement______respondents
O Utilize informatics______respondents
O Medical knowledge______respondents
O Employ evidence-based practice______respondents
O None of the above______respondents
CME Form 108 Evaluation Summary
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9.How will you change your practice as a result of attending this session(select all that apply)?
O Create/revise protocols, policies, and/or procedures______respondents
O Change the management and/or treatment of my patients______respondents
O This activity validated my current practice______respondents
O I will not make any changes to my practice because ______respondents
O Other, please specify:______respondents
10.Please indicate any barriers you perceivefor implementing these changes.
CME Form 108 Evaluation Summary
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O Cost______respondents
O Lack of experience______respondents
O Lack of opportunity (patients)______respondents
O Lack of resources (equipment)______respondents
O Lack of administrative support ______respondents
O Lack of time to assess/counsel patients______respondents
O Reimbursement/insurance issues______respondents
O Patient compliance issues______respondents
O Lack of consensus or professional guidelines______respondents
O No barriers______respondents
O Other______respondents
CME Form 108 Evaluation Summary
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11.How will you address these barriers to implement changes in knowledge and/or behavior?
Please list any responses
12.What changes might be made in the overall format of this CME activity in order to be the most appropriate for the content presented (select all that apply)?
O Format is appropriate; no changes needed______respondents
OAdd a hands-on instructional component______respondents
OInclude more case-based presentations______respondents
OSchedule more time for Q and A______respondents
OIncrease interactivity with attendees______respondents
OOther______respondents
Put a check in the box to indicate the average response rating the speakers. If you have your own ranking scale for speakers of this activity please submit the average score relating to your own speaker evaluation.
14. Speaker(s) (Overall) / Excellent / Above Average / Average / Below Average / PoorOverall Presentation
Organized Presentation: clearly presented and explained concepts
Useful, relevant & practical information
Comments: Please type up any relevant comments that will be effective in planning and implementing future CME activities:
TOTAL # OF RESPONDENTS FOR THIS CME ACTIVITY / TOTAL # OF REGISTRANTS FOR THIS CME ACTIVITYCME Form 108 Evaluation Summary