Joint Provider- Participant Evaluation

Please fill out the program evaluation as, your candid and thorough completion of this evaluation will aid Vassar Brothers Continuing Medical Education in continually improving the quality of its programs.

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* 1. Joint Provider Name:

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* 2. Event Title:

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* 3. Date of Conference

Date / Time

Date

Time

AM/PM

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* 4. How did you hear about this conference?

Colleague

Website

E-mail

Facebook

Twitter

Other (please specify)

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* 5. Please indicate how the information you learned; will be applied to your practice or, help you achieve your desired result.

Differential diagnosis

Change in treatment or patient care management

Change in medication administration and/or management

Decision-making for consultation or referral

Update current understanding or improve knowledge

Understand and apply most current standard of care

Performance Improvement (PI)

Protocol development or guideline implementation

Reduce costs or improve efficiency

Improve patient education

Knowledge base in preparation for a presentation

Reduce length of stay

Other (please specify)

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

Yes

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* 7. Did you perceive any conflict of interest in the presentations? If so, what?

Yes (please specify):

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* 8. Please evaluate whether or not the presenters did the following:

	Yes	No
Related content to relevant medical practice?	Related content to relevant medical practice? Yes	Related content to relevant medical practice? No
Stimulated my desire to learn?	Stimulated my desire to learn? Yes	Stimulated my desire to learn? No
Held my attention?	Held my attention? Yes	Held my attention? No
Used AV in a helpful manner?	Used AV in a helpful manner? Yes	Used AV in a helpful manner? No

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* 9. In what ways could the presenters improve?

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* 10. Were there technical difficulties?

Yes ---->

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* 11. 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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* 12. Comments & Suggestion for future activities:

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* 13. 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: