2012 Arizona Infectious Disease Training & Exercise

1. About Continuing Educaiton for this Event

The GVAHEC is pleased to provide continuing education for this event. The following questions are REQUIRED in order to receive continuing education. You must complete the evaluation of learning objectives for each session that you attended and for which you are requesting credit.
Please be sure to provide a VALID email address. Continuing education certificates will be emailed to you as a PDF. Please allow 10 business days for processing.

If you do not receive your certificate within 10 business days of submitting you request please email:
acarter@gvahec.org or call 480-288-8260.
Anyone requesting continuing education certificates or certificates of completion must do so within 30 days of the event.

Please provide the following information as you would like it to appear on your certificate.

Please provide the following information as you would like it to appear on your certificate. Prefix (If Applicable)
First Name
Last Name
Suffix, credentials (if applicable)

YOUR CERTIFICATE WILL BE EMAILED IN 10 Business DAYS>>>>Please provide a valid email address where your certificate will be sent and a phone number in case we have questions.

YOUR CERTIFICATE WILL BE EMAILED IN 10 Business DAYS>>>>Please provide a valid email address where your certificate will be sent and a phone number in case we have questions. email
Daytime phone

Which days of the conference did you attend?

Which days of the conference did you attend? Tuesday July 31, 2012

Wednesday August 1, 2012

Thursday August 2, 2012

How many CE hours are you requesting?

Are you requesting continuing education for: (Select all that apply)

Are you requesting continuing education for: (Select all that apply) Nurses (Please enter any license information below)

Physicians (American Academy of Family Physicians)

Registered Sanitarian

Community Health Education Specialists (CHES)

Arizona Board of Examiners - Nursing Care Institution Administrators and Assisted Living Facility Managers

Certificate of participation

If applicable, please include your license or registration number at is pertains to the certificates you requested above. If you selected "Certificate of Participation" no license number is required.

CE/CME Participant Satisfaction Survey
Please circle the number that best describes your agreement with the following statements.

1 Strongly Disagree
2 Disagree
3 No Opinion
4 Agree
5 Strongly Agree

	1	2	3	4	5
The educational objectives were well met.	*CE/CME Participant Satisfaction Survey Please circle the number that best describes your agreement with the following statements. 1 Strongly Disagree 2 Disagree 3 No Opinion 4 Agree 5 Strongly Agree The educational objectives were well met. 1	The educational objectives were well met. 2	The educational objectives were well met. 3	The educational objectives were well met. 4	The educational objectives were well met. 5
The speaker(s) demonstrated a thorough knowledge of the subject matter.	The speaker(s) demonstrated a thorough knowledge of the subject matter. 1	The speaker(s) demonstrated a thorough knowledge of the subject matter. 2	The speaker(s) demonstrated a thorough knowledge of the subject matter. 3	The speaker(s) demonstrated a thorough knowledge of the subject matter. 4	The speaker(s) demonstrated a thorough knowledge of the subject matter. 5
The presentation content related appropriately to the objectives.	The presentation content related appropriately to the objectives. 1	The presentation content related appropriately to the objectives. 2	The presentation content related appropriately to the objectives. 3	The presentation content related appropriately to the objectives. 4	The presentation content related appropriately to the objectives. 5
I would recommend this program to my colleagues.	I would recommend this program to my colleagues. 1	I would recommend this program to my colleagues. 2	I would recommend this program to my colleagues. 3	I would recommend this program to my colleagues. 4	I would recommend this program to my colleagues. 5
The training program /conference reflected current issues.	The training program /conference reflected current issues. 1	The training program /conference reflected current issues. 2	The training program /conference reflected current issues. 3	The training program /conference reflected current issues. 4	The training program /conference reflected current issues. 5
The speaker (s) applied the material covered to the practice setting.	The speaker (s) applied the material covered to the practice setting. 1	The speaker (s) applied the material covered to the practice setting. 2	The speaker (s) applied the material covered to the practice setting. 3	The speaker (s) applied the material covered to the practice setting. 4	The speaker (s) applied the material covered to the practice setting. 5
I attended this program because the content was relevant to my practice.	I attended this program because the content was relevant to my practice. 1	I attended this program because the content was relevant to my practice. 2	I attended this program because the content was relevant to my practice. 3	I attended this program because the content was relevant to my practice. 4	I attended this program because the content was relevant to my practice. 5
My expectations for this program were well met.	My expectations for this program were well met. 1	My expectations for this program were well met. 2	My expectations for this program were well met. 3	My expectations for this program were well met. 4	My expectations for this program were well met. 5
The speaker(s) demonstrated product bias during the presentation.	The speaker(s) demonstrated product bias during the presentation. 1	The speaker(s) demonstrated product bias during the presentation. 2	The speaker(s) demonstrated product bias during the presentation. 3	The speaker(s) demonstrated product bias during the presentation. 4	The speaker(s) demonstrated product bias during the presentation. 5
Please rate the overall quality of the speakers.	Please rate the overall quality of the speakers. 1	Please rate the overall quality of the speakers. 2	Please rate the overall quality of the speakers. 3	Please rate the overall quality of the speakers. 4	Please rate the overall quality of the speakers. 5

Other (please specify)

Of all the factors that influence your satisfaction in your current practice setting, how would you rate the provision of Continuing Education Opportunities? (Select One)

Of all the factors that influence your satisfaction in your current practice setting, how would you rate the provision of Continuing Education Opportunities? (Select One) No Importance

Little Importance

Moderate Importance

High Importance

Other (please specify)

Please select your primary occupation.

Please select your primary occupation. Physician (allopathic)

Mental Health

Physician (osteopathic)

Physical Therapist

Advanced Practice Nurse

Public Health

Nurse

Community Health Worker

Physicians Assistant

Allied Health

Pharmacist

Health Administrator

Dentist

Preventive Medicine Practitioners

Social Worker

Clinical Psychologists

Nurse Anesthetists

Chiropractor

Dietitian/ Dietetic Technician

Other (please specify)

What is your current employment location or setting?

What is your current employment location or setting? Community Health Center

Private Practice or Clinic

Hospital

Military Base

Indian Health Services/Tribal Health Site

Migrant Health Center

Health Department

Health Care for Homeless

Governor Designated Area

Public Health/Primary Care Grantees

Urban Community-Based Training Site

Rural Health Clinic

Other AHEC Community-Based Site

National Health Service Corp Site

Other (please specify)

What is your ethnicity

What is your ethnicity Asian (Chinese, Filipino, Japanese, Korean, Asian Indian, Thai)

Native American (Please Specify Tribe below)

Asian (other)

Hispanic

African American

Caucasian

Native Hawaiian or Pacific Islander

Other (please specify)

Age Range:

Age Range: Under 20

20 - 29

30 - 39

40 - 49

50 - 59

60 or Older

Gender

Gender Male

Female

Languages Spoken

Languages Spoken Primary:
Other Languages your are fluent in speaking:

Would you like to receive emails regarding other continuing education events and opportunities from the Greater Valley Area Health Education Center? (we will use the email you provided unless you specify otherwise below)

No Thanks

Alternate email

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