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* 1. Name 

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* 2. Credentials

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* 3. ADDRESS/CITY/STATE/ZIPCODE

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* 4. LICENSE NUMBER

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* 5. SPECIALTY

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* 6. EMAIL ADDRESS 

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* 7. This CME activity has increased, improved, or positively impacted my: (select all that apply)

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* 8. This activity is free of commercial bias* or influence.

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* 9. The overall objective was met.

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* 10. This activity met my educational needs.

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* 11. The references were appropriate. 

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* 12. The educational format(s) is appropriate for the setting, objective, and desired result.

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* 13. The content matches my current or potential scope of professional activities

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* 14. This activity has addressed competencies that are applicable with the following (select all that apply):

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* 15. This activity has addressed ethics competencies (select all that apply):

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* 16. What changes might be made in the overall format of this CME activity in order to be the most appropriate for the content presented? (select all that apply) 

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* 17. Will this activity change your practice in medicine?

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* 18. How will you change your practice as a result of attending this activity? (select all that apply)

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* 19. Please indicate any barriers you perceive for implementing these changes.

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* 20. How will you address these barriers to implement changes in knowledge and/or behavior?

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* 21. Would you be willing to participate in a follow-up survey via mail/email in 3-6 months?

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* 22. DR. LINDA HU: The speaker was qualified/effective

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* 23. DR. LINDA HU EVALUATION:  The content presented was objective and free of commercial bias

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* 24. DR. LINDA HU EVALUATION:   Visual aids/handouts were helpful

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* 25. DR. ASHU DHANJAL EVALUATION: The speaker was qualified/effective

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* 26. DR. ASHU DHANJAL EVALUATION: The content presented was objective and free of commercial bias.

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* 27. DR. ASHU DHANJAL EVALUATION: Visual aids/handouts were helpful

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* 28. DR. HANY JEFFRY EVALUATION: The speaker was qualified/effective

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* 29. DR. HANY JEFFRY EVALUATION: The content presented was objective and free of commercial bias.

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* 30. DR. HANY JEFFRY EVALUATION:  Visual aids/handouts were helpful

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* 31. DR. SHALAKA GHATE EVALUATION: The speaker was qualified/effective

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* 32. DR. SHALAKA GHATE EVALUATION:  The content presented was objective and free of commercial bias.

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* 33. DR. SHALAKA GHATE EVALUATION:  Visual aids/handouts were helpful.

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* 34. DR. ANDREA DENEEN EVALUATION:  The speaker was qualified/effective

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* 35. DR. ANDREA DENEEN EVALUATION: The content presented was objective and free of commercial bias.

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* 36. DR. ANDREA DENEEN EVALUATION: Visual aids/handouts were helpful.

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* 37. JENNIFER MCGRATH EVALUATION:  The speaker was qualified/effective

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* 38. JENNIFER MCGRATH EVALUATION: The content presented was objective and free of commercial bias.

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* 39. JENNIFER MCGRATH EVALUATION: Visual aids/handouts were helpful.

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* 40. What topics would you suggest for future meetings? 

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