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* 1. First Name (required):

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* 2. Last Name (required)

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* 3. This activity met with my current professional needs.

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* 4. Upon completion of this activity, I feel empowered to implement specific changes or strategies that will enhance my professional practice and competence.

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* 5. The content of this activity served to enhance my professional practice and competence.

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* 6. It is clear to me how I would implement the desired learning outcomes (changes or new strategies) in my practice, if given the chance.

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* 7. The content of this CME activity matches my scope of professional practice (i.e. primary care, specialty, subspecialty, healthcare team member, administrative staff member, hospitalist, healthcare executive, etc.)

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* 8. The selected faculty members, moderators and/or facilitators met with my professional expectations.

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* 9. The educational design and format chosen for this activity were appropriate for the setting, and desired learning outcomes.

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* 10. In what way could this CME activity be improved? (Please respond in terms of content, faculty selection, learning outcomes or expected changes, etc)

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* 11. What were some of the strengths of this CME activity?

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* 12. As a result of this activity, and in striving for ideal professional practice and competence, I will make the following changes: • Yes Please List Three (3) Changes:

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* 13. Did this CME activity actively promote improvements in health care that were free of commercial bias and/or promotion?

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* 14. Please list at least (3) professional practice gaps (educational needs or problem areas) that you would like to see addressed for your practice in future CME activities:

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* 15. Signature (required):

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