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1. Title of Activity:

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2. Date of Presentation

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3. Name & Contact Information:

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4. Birth Date: (MM/DD Format)

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5. In order to improve the quality of these sessions, we would appreciate your completing this short evaluation. All responses are strictly confidential.

Professional category

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6. How satisfied were you with today's presentation?

1 - Very Dissatisfied 5 - Very Satisfied
Clear
i We adjusted the number you entered based on the slider’s scale.

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7. Name one way your knowledge about the profession and the practice of medicine has changed as a result of today's session:

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8. Name one way your knowledge has changed as a result of today's session and how you will apply this knowledge to your clinical practice in one of the following competencies: professionalism, interpersonal skills, patient care, self-awareness, cultural sensitivity/diversity or other area.

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9. Please rate the relevance of the material to your particular interest and needs:

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10. List suggestions or comments you have regarding future topics you would like addressed, or ideas on how these sessions could be improved (optional):

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11. You feel this activity was free of commercial bias or influence? If no, please explain
*Commercial bias is defined as a personal judgement in favor of a specific product or service of an ineligible company.

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12. Do you feel this activity was evidence-based? If not, please explain.

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