ILLINOIS NURSES ASSOCIATION

Evaluation Form

Live Presentation

Please Read the Following Directions Before Completing the Evaluation Form Below.

1. All the items that appear on this evaluation form are required but other questions may be included.

2.For live educational activities that consist of multiple topics or sessions, such as conferences and conventions, it is advisable to develop:

a.An overall evaluation form with general questions.

b.An evaluation form for each session listing the objectives, presenters/content specialists and questions regarding content integrity and disclosure of conflict of interest or lack thereof.

OBJECTIVES

The providing organization of the activity should list the learner objectives (or a global representation of the objectives) on the Educational Activity Overview form in the objectives’ section. You may add additional boxes if necessary.

PRESENTERS/CONTENT SPECIALISTS

The providing organization of the activity must list the name of each presenter or content specialist in the presenters’/content specialists’ section.

OTHER

In addition to objectives and presenters, other questions are required on the evaluation tool.

(PLEASE DELETE THIS INTRODUCTORY PAGE BEFORE SUBMITTING THE APPLICATION TO INA.)

Evaluation Form

Live Presentation

Name of Providing Organization:
Title of educational activity:
Date(s):

Please assist us in evaluating this educational activity and planning future activities by completing this evaluation form.

Question regarding disclosure of planners’ and presenters’ conflict of interest(s):

Has the provider of the activity disclosed in writing the absence or presence conflict of interest declared by the planners and presenters/content specialists? / YES / NO

Question regarding Content Integrity:

Was the content presented without bias of any commercial product or drug? / Yes / No

OBJECTIVES

Please use the following rating scale to evaluate the objectives by circling the corresponding number below.

To a Great Extent = 4To a Moderate Extent = 3

To a Slight Extent = 2Not at All = 1

I have achieved the following objectives as a result of this educational activity:

Objective # 1:
4 / 3 / 2 / 1
Objective # 2:
4 / 3 / 2 / 1
Objective # 3:
4 / 3 / 2 / 1

PRESENTERS/CONTENT SPECIALISTS

Rate the teaching effectiveness/expertise of EACH presenter:

Please use this rating scale to evaluate the following by circling the corresponding number below.

Excellent = 4Good= 3 Fair = 2Poor= 1

Presenter/Content Specialist
4 / 3 / 2 / 1
Presenter/Content Specialist
4 / 3 / 2 / 1
Presenter/Content Specialist
4 / 3 / 2 / 1
Additional Comments:

1

Revised 11/09