CME Survey

Question Title

* 1. Participant Information

Full Name and Credentials
Ex. John Doe, MD, PhD *

Organization/Healthcare Facility *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

Question Title

* 2. This activity is eligible for a maximum of 15-18 educational credits. In the space below type in the number of credits that you are requesting for this educational activity. You should claim only credit commensurate with the extent of your participation in the activity.

Question Title

* 3. Please indicate the type of credit requested:

CME

CNE

Question Title

* 4. Please evaluate the level of achievement of this activity. Please use the following scale to respond to the questions below:

	Strongly Agree	Agree	Neither Agree or Disagree	Disagree	Strongly Disagree
The provider of this activity disclosed verbally or in writing the absence or presence of potential conflicts of interest on the part of planners and presenters.	The provider of this activity disclosed verbally or in writing the absence or presence of potential conflicts of interest on the part of planners and presenters. Strongly Agree	The provider of this activity disclosed verbally or in writing the absence or presence of potential conflicts of interest on the part of planners and presenters. Agree	The provider of this activity disclosed verbally or in writing the absence or presence of potential conflicts of interest on the part of planners and presenters. Neither Agree or Disagree	The provider of this activity disclosed verbally or in writing the absence or presence of potential conflicts of interest on the part of planners and presenters. Disagree	The provider of this activity disclosed verbally or in writing the absence or presence of potential conflicts of interest on the part of planners and presenters. Strongly Disagree
The content of this activity was presented without bias toward any commercial product.	The content of this activity was presented without bias toward any commercial product. Strongly Agree	The content of this activity was presented without bias toward any commercial product. Agree	The content of this activity was presented without bias toward any commercial product. Neither Agree or Disagree	The content of this activity was presented without bias toward any commercial product. Disagree	The content of this activity was presented without bias toward any commercial product. Strongly Disagree
The Facilitator(s)/Presenter(s) demonstrated content expertise.	The Facilitator(s)/Presenter(s) demonstrated content expertise. Strongly Agree	The Facilitator(s)/Presenter(s) demonstrated content expertise. Agree	The Facilitator(s)/Presenter(s) demonstrated content expertise. Neither Agree or Disagree	The Facilitator(s)/Presenter(s) demonstrated content expertise. Disagree	The Facilitator(s)/Presenter(s) demonstrated content expertise. Strongly Disagree
This activity met my expectations based on the stated goals and objectives.	This activity met my expectations based on the stated goals and objectives. Strongly Agree	This activity met my expectations based on the stated goals and objectives. Agree	This activity met my expectations based on the stated goals and objectives. Neither Agree or Disagree	This activity met my expectations based on the stated goals and objectives. Disagree	This activity met my expectations based on the stated goals and objectives. Strongly Disagree
The teaching method(s) used were effective for learning.	The teaching method(s) used were effective for learning. Strongly Agree	The teaching method(s) used were effective for learning. Agree	The teaching method(s) used were effective for learning. Neither Agree or Disagree	The teaching method(s) used were effective for learning. Disagree	The teaching method(s) used were effective for learning. Strongly Disagree
The knowledge and/or skills I have acquired from this activity are directly applicable to my professional practice.	The knowledge and/or skills I have acquired from this activity are directly applicable to my professional practice. Strongly Agree	The knowledge and/or skills I have acquired from this activity are directly applicable to my professional practice. Agree	The knowledge and/or skills I have acquired from this activity are directly applicable to my professional practice. Neither Agree or Disagree	The knowledge and/or skills I have acquired from this activity are directly applicable to my professional practice. Disagree	The knowledge and/or skills I have acquired from this activity are directly applicable to my professional practice. Strongly Disagree
I intend to apply the knowledge and/or skills I have acquired from this activity to my practice/area of work.	I intend to apply the knowledge and/or skills I have acquired from this activity to my practice/area of work. Strongly Agree	I intend to apply the knowledge and/or skills I have acquired from this activity to my practice/area of work. Agree	I intend to apply the knowledge and/or skills I have acquired from this activity to my practice/area of work. Neither Agree or Disagree	I intend to apply the knowledge and/or skills I have acquired from this activity to my practice/area of work. Disagree	I intend to apply the knowledge and/or skills I have acquired from this activity to my practice/area of work. Strongly Disagree
I have a strategy/strategies to make change(s) in my professional practice based the knowledge and/or skills I have acquired from this activity.	I have a strategy/strategies to make change(s) in my professional practice based the knowledge and/or skills I have acquired from this activity. Strongly Agree	I have a strategy/strategies to make change(s) in my professional practice based the knowledge and/or skills I have acquired from this activity. Agree	I have a strategy/strategies to make change(s) in my professional practice based the knowledge and/or skills I have acquired from this activity. Neither Agree or Disagree	I have a strategy/strategies to make change(s) in my professional practice based the knowledge and/or skills I have acquired from this activity. Disagree	I have a strategy/strategies to make change(s) in my professional practice based the knowledge and/or skills I have acquired from this activity. Strongly Disagree

Certificates will be emailed by Rush University to the email address provided above.

Certificates Administered by:

Interprofessional Continuing Education

312-942-7119

CE_Office@rush.edu

Rush University Medical Center is accredited by the Accreditation Council for Continuing Medical Education