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Department of Health Humanities & Bioethics CME Form

1.Title of Activity:
2.Date of Presentation
3.Name & Contact Information:
4.Birth Date: (MM/DD Format)
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
6.How satisfied were you with today's presentation?
1 - Very Dissatisfied
5 - Very Satisfied
7.Name one way your knowledge about the profession and the practice of medicine has changed as a result of today's session:
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.
9.Please rate the relevance of the material to your particular interest and needs:
10.List suggestions or comments you have regarding future topics you would like addressed, or ideas on how these sessions could be improved (optional):
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.
12.Do you feel this activity was evidence-based? If not, please explain.