Use this template to evaluate a CME activity that had multiple presentations.

INSTRUCTIONS: Replace all RED text below with info about your activity. Then, change all text to black and delete these header sentences.

CME Activity Evaluation
Conference Name • Department Name (if applicable)

Your responses below will help us improve the effectiveness of this activity in the future.

Please circle the number that most accurately reflects your opinion of each presentation and speaker.

1=poor, 2=below average, 3=average, 4=good, 5=excellent

Presentation Title & Speaker: / Content Usefulness: / Presentation Quality: / Free of Commercial Bias?
Short Presentation Title -Speaker Name, DEGREE / 1 2 3 4 5 / 1 2 3 4 5 / 1 2 3 4 5
Really Long Presentation Title: With a Colon and Additional Description -Speaker Name, DEGREE / 1 2 3 4 5 / 1 2 3 4 5 / 1 2 3 4 5
Insert or Delete Rows as needed to account for each presentation

Please rate your ability to do the following at the conclusion of this program:

1)First learning objective from your CME Credit Application for this activity:
☐I can do all of this
☐I can do most of this, but not all of it
☐I can do about half of this
☐I am only able to do a little bit of this
☐I am not able to do any of this / 2)Second learning objective from your CME Credit Application for this activity:
☐I can do all of this
☐I can do most of this, but not all of it
☐I can do about half of this
☐I am only able to do a little bit of this
☐I am not able to do any of this
3)Third learning objective from your CME Credit Application for this activity:
☐I can do all of this
☐I can do most of this, but not all of it
☐I can do about half of this
☐I am only able to do a little bit of this
☐I am not able to do any of this / 4)Fourth learning objective from your CME Credit Application for this activity:
☐I can do all of this
☐I can do most of this, but not all of it
☐I can do about half of this
☐I am only able to do a little bit of this
☐I am not able to do any of this

What impact will this activity have on your professional medical practice?

☐No change ☐I will improve my practice in minor ways ☐I will improve my practice in major ways

In what ways do you expect this activity to improve your professional medical practice?

☐Knowledge ☐Competence ☐Performance ☐Patient Outcomes

Please list any specific ways you plan to improve your practice based on what you learned from these presentations:

______

Please list any ways this activity could be improved or aspects that hindered your learning:______

______

Did you perceive any product/service promotion during the education? ☐NO ☐YES, please explain:______

______

Present Status:____ Licensed MD/DO ____ Resident MD/DO ____Medical Student ____PA/NP/RN ____Other: ______