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Lectures *

Name

First

Last

MD

APN

PA

RN

MA

Other

Specialty

Institution/Practice

Address:

Email:

Phone Number:

ACTIVITY:

Presenter:

Tittle:

Date:

Single Item *

Price: $25.00

PRE-TEST:

A
B
C
D

Email: Specialty increased

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POST-TEST:

A
B
C
D

Fill The EVALUATION FORM

Speaker

Topic title

Date

CME EVALUATION FORM Please rate the impact of the following objectives:

As a result of attending this activity, I am better able to:

1. Discuss and explain the etiologies of ....

Strongly Disagree 1
Disagree 2
Neutral 3
Agree 4
Strongly Agree 5

2. Diagnose different complications of the condition.

Strongly Disagree 1
Disagree 2
Neutral 3
Agree 4
Strongly Agree 5

3. Apply updated therapies to specific clinical cases.

Strongly Disagree 1
Disagree 2
Neutral 3
Agree 4
Strongly Agree 5

1. Please rate the projected impact of this activity on your knowledge, competence, performance, and patient

outcomes*: competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something).

This activity increased my knowledge.

Yes
No
No Change

This activity increased my competence.

Yes
No
No Change

This activity improved my performance.

Yes
No
No Change

This activity will improve my patient outcomes.

Yes
No
No Change

If yes, please describe:

*Medical Society of New Jersey requires that we analyze changes in learners’ competence, performance, or patient outcomes.

2. Please identify how you will change your practice as a result of attending this activity:

3. Please indicate any barriers you perceive in implementing these changes

Cost
Lack of experience
Lack of opportunity (patients)
Lack of resources (equipment)
Lack of administrative support

Lack of time to assess/counsel patients
Reimbursement/insurance issues
Patient compliance issues
Lack of consensus or professional guidelines
No barriers
Other

Please specify:

4. Will you attempt to address these barriers in order to implement changes in your competence, performance,
and/or patients’ outcomes?

N/A
No

Why not?

Yes

How?

5. Please indicate which of the following American Board of Medical Specialties/Institute of Medicine core
competencies were addressed by this educational activity (select all that apply):

Patient care or patient-centered care
Interpersonal and communication skills
Practice-based learning & improvement
Professionalism
System-based practice
Interdisciplinary teams
Quality improvement
Utilize informatics
Medical knowledge
Employ evidence-based practice
None of the above

6. The content of this activity matched my current (or potential) scope of practice. Yes No, please explain:

7. How might the format of this activity be improved for the content presented (select all that apply)?

Format was appropriate; no changes needed
Include more case-based presentations
Increase interactivity with attendees
Add breakouts for Subtopics
Add a hands-on instructional component
Schedule more time for Q and A
Other

describe:

8. Overall, were the speakers knowledgeable regarding the content? (copy)

Yes
No

please explain:

9. Overall, was the presentation balanced, objective, and scientifically rigorous?

Yes
No

please explain:

10. Was there an opportunity to discuss practice-relevant issues with the speaker?

Yes
No

please explain:

11. Did the presentation meet your needs or expectations:

12. Do you feel the activity was scientifically sound and free of commercial bias* or influence?

Yes
No

please explain:

*Commercial bias is defined as a personal judgment in favor of a specific product or service of a commercial interest.

13. Speaker’s disclosure was communicated verbally or in writing

Yes
No

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Department

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Form

Registration Forms

ACTIVITY:

Fill The EVALUATION FORM

CME EVALUATION FORM Please rate the impact of the following objectives:

1. Please rate the projected impact of this activity on your knowledge, competence, performance, and patient

3. Please indicate any barriers you perceive in implementing these changes

4. Will you attempt to address these barriers in order to implement changes in your competence, performance, and/or patients’ outcomes?

5. Please indicate which of the following American Board of Medical Specialties/Institute of Medicine core competencies were addressed by this educational activity (select all that apply):

7. How might the format of this activity be improved for the content presented (select all that apply)?

4. Will you attempt to address these barriers in order to implement changes in your competence, performance,
and/or patients’ outcomes?

5. Please indicate which of the following American Board of Medical Specialties/Institute of Medicine core
competencies were addressed by this educational activity (select all that apply):