Data Collection

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* 1. Date of Activity

Date / Time

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* 2. Name of Activity

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* 3. Name of person completing the survey

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* 4. Total Number of Respondants

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* 5. Based on an analysis of your evaluation data, how effective was this activity in:

  Very Effective Effective Neutral Ineffective Very Ineffective
Meeting the overall objectives of the event?
Improving the knowledge level of the learners?
Improving the competence level of the learners?
Improving the performance of the learners?
Improving patient outcomes?

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* 6. What actions will you take to improve the effectiveness for changing learner behavior or patient outcomes?

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* 7. Was this activity Interprofessional?

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* 8.
Please indicate how effective the activity was in improving the learner's ability to:

  Very Effective Effective Neutral Ineffective Very Ineffective
Apply the knowledge and/or skills acquired from this activity to their work when in a team environment.
Collaborate with a multidisciplinary team.
Communicate with other members of a multidisciplinary team.
Discuss how teamwork can contribute to continuous and reliable patient care.

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* 9. Please indicate which of the following American Board of Medical Specialties/Institute of Medicine core competencies have been addressed by this activity(select all that apply):

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* 10. Please indicate which of the interprofessional core competencies were addressed during the activity (select all that apply)

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* 11. What barriers did you or your learners identify as potentially preventing their incorporating what they learned in this activity into their work? (select all that apply)

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* 12. Please indicate ideas you may use to address the identified barriers in future activities (mark all that apply):

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* 13. Based on an analysis of the participants in the activity, to what extent did the activity reach the targeted audience?

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* 14. Based on the percentage of targeted audience participating in the activity, how satisfied are you with reaching the targeted audience

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* 15. To improve reaching the targeted audience which of the options would you plan to use:

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* 16. Analysis of the evaluations shows it was scientifically sound and free of commercial bias

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* 17. Analysis of the evaluations show that overall the  presentations were balanced, objective and scientifically rigorous.

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* 18. Were any new instructional strategies included in this activity?

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* 19. Were there other outcomes or achievements that occured as a result of this activity?

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