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* 1. First and Last Name:

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* 2. Mailing Address:

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* 3. Email address to send activity certificate:

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* 4. Indicate your profession (MD, DO, NP, etc.):

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* 5. How many years have you been in practice?

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* 6. State(s) where License is held:

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* 7. License Number(s):

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* 8. Post Test: Which of the following fields provides a strong model of communication, which the medical field could potentially employ to enhance patient care and treatment success?

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* 9. Post Test: The “Center Effect” refers to which of the following?

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* 10. Post Test: Crew Resource Management (CRM) and Human Factors are about effective communication to improve safety. Which of the following statement would best characterize CRM?

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* 11. As an integral part of your educational experience, please reflect upon the knowledge you have learned in this educational activity and demonstrate how you would apply that knowledge to practice in the following clinical vignette and questions below:

A nurse on the medical staff at your dialysis center recently made a medical error when she used an incorrect dialysate on a patient with ESRD. This error was not consistent with your instructions, and the patient nearly died.

Which is the best strategy to make sure the mistake doesn’t occur again?

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* 12. Based on what you learned in this educational activity, please tell us one or two specific changes in your practice you are committed to make:

Thank you for reflecting on immediate response to this educational experience. We will be contacting you by e-mail in approximately two-to-four months to ask a few additional questions that help us to know if you did, indeed, implement what you learned. Please take a few minutes to respond to this questionnaire upon receipt.
Ultimate Medical Academy (UMA) educators strive to ensure that any educational activity offered for credit meets all requirements of the Standards for Commercial Support. Toward that end, please tell us about your experience is this activity:

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* 13. Were you provided with disclosure of relevant financial relationships of all persons affecting the content of this activity?

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* 14. Were the commercial supporters of this activity acknowledged in course materials?

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* 15. Were any commercial products displayed on the website?

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* 16. Were product names avoided in this activity, or if used were all products referenced by their trade name?

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* 17. Were all presentations free of commercial bias?

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* 18. If commercial bias was present, indicate below the specific presentations:

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* 19. Please provide UMA educators with areas of need and/or gaps in your own practice that you would like to see offered in future educational activities sponsored by UMA:

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* 20. CLAIM FOR CREDIT

This educational activity was certified for 0.25 AMA PRA credits for physicians.

Physician and nurse learners must claim credit for actual time spent at the activity up to the maximum for which the activity was certified. Pharmacists must attend the entire activity in order to receive credit. Please indicate the number of hours and minutes rounded up or down to the nearest quarter hour that you spent in this activity:

Maximum Credits Offered: 0.25

Thank you for participating in this educational activity. Your certificate will be emailed to you within 30-days.

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