Joint Provider- Program Evaluation by Education or Course Director

Please take a moment to fill out the evaluation

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* 1. Joint Provider Name:

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* 2. Event Title:

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* 3. Education/Course Director:

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* 4. Date/Time

Date / Time

Date

Time

AM/PM

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* 5. Please circle the number indication your response

	excellent	very good	needs work	poor	N/A
Was the speaker effective- organized, understandable, tasteful?	Was the speaker effective- organized, understandable, tasteful? excellent	Was the speaker effective- organized, understandable, tasteful? very good	Was the speaker effective- organized, understandable, tasteful? needs work	Was the speaker effective- organized, understandable, tasteful? poor	Was the speaker effective- organized, understandable, tasteful? N/A
Was there enough interaction between the speaker and audience?	Was there enough interaction between the speaker and audience? excellent	Was there enough interaction between the speaker and audience? very good	Was there enough interaction between the speaker and audience? needs work	Was there enough interaction between the speaker and audience? poor	Was there enough interaction between the speaker and audience? N/A
Was the information offered accurate, scientific and balanced?	Was the information offered accurate, scientific and balanced? excellent	Was the information offered accurate, scientific and balanced? very good	Was the information offered accurate, scientific and balanced? needs work	Was the information offered accurate, scientific and balanced? poor	Was the information offered accurate, scientific and balanced? N/A
Was the information offered clinically relevant?	Was the information offered clinically relevant? excellent	Was the information offered clinically relevant? very good	Was the information offered clinically relevant? needs work	Was the information offered clinically relevant? poor	Was the information offered clinically relevant? N/A
Were the visual aids clear and easy to understand?	Were the visual aids clear and easy to understand? excellent	Were the visual aids clear and easy to understand? very good	Were the visual aids clear and easy to understand? needs work	Were the visual aids clear and easy to understand? poor	Were the visual aids clear and easy to understand? N/A

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* 6. Was potential faculty conflict-of-interest (disclosure) conveyed to the audience prior to the activity?

Yes

No

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* 7. What were the program's strengths?

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* 8. What were the Programs Weaknesses?

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* 9. What changes would you make for a future program?

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* 10. Do you have suggestions for additional learning?

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* 11. Were there technical difficulties?

No

Yes ---->

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* 12. If yes, did they affect your ability to do the following?:

	Yes	No
See	See Yes	See No
Hear	Hear Yes	Hear No
Learn	Learn Yes	Learn No

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* 13. Would you consider having the speaker return? (please circle one)

No

Yes

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* 14. Please provide your name and contact information, so that we may contact you if we have any questions regarding your responses. (This information is not required)

Name:

Title:

Email Address:

Specialty: