1.First Name (required):

2.Last Name (required)

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)

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?

Yes

No

If No, please explain why?

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):