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Evaluation Form
GAPNA - September 30
To help us improve and develop future programs, please complete the following evaluation form.
1.
Enter your name:
2.
Specialty (please select one):
Psychiatrist
Neurologist
Geriatrician
Primary Care Physician
Physician Assistant
Nurse (please specify below)
Other (please specify)
3.
Please enter your information below
Address
Address 2
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Country
Enter your email address if you would like to receive information about samples
NPI Number
4.
Please answer each statement by checking the rating under the heading that best describes your views:
Excellent
Very Good
Good
Adequate
Poor
Very Poor
This presentation represented educational value for time spent
Excellent
Very Good
Good
Adequate
Poor
Very Poor
Please rate the ef
fectiveness of Jason Kellogg's p
resentation
Excellent
Very Good
Good
Adequate
Poor
Very Poor
5.
Please answer each statement by clicking the circle that best describes how confident you are:
Not Confident
Very Confident
Prior to the presentation, how confident were you in your understanding of the treatment presented?
After the presentation, how confident are you in your understanding of the treatment presented?
Prior to the presentation, how confident were you in your understanding of hallucinations and delusions associated with Parkinson's disease psychosis?
After the presentation, how confident were you in your understanding of hallucinations and delusions associated with Parkinson's disease psychosis?
6.
After attending this program, will you use what you have learned in your day-to-day clinical practice?
Yes
No
Not Sure
7.
Were there any aspects that you felt should have been covered but were not addressed? (Please select all that apply)
Dosage and administration of the treatment presented
The proposed neurobiology for Parkinson's disease psychosis
Documentation of diagnosis, symptoms, and treatment for monitoring
Support for patients in long-term care, including CMS guidance pertaining to the indefinite use of the treatment presented without gradual dose reduction
Long-term safety data for the treatment presented
All topics were covered well
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