"Cme Activity Program Evaluation Form - Santa Clara Valley Medical Center"

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Your comments are essential for improving the effectiveness of SCVMC continuing medical education activities. Please
complete this questionnaire and return it at the end of the activity.
TITLE:
DATE:
SPEAKER:
REVIEWER:
Educational Objectives:
1.
2.
3.
Please indicate how well this activity addressed the educational objectives:
Education
Very
Poor
Fair
Good
Excellent
Good
Objective
# 1
1
2
3
4
5
# 2
1
2
3
4
5
# 3
1
2
3
4
5
1. Please rate the effectiveness of the presentation (as above scoring):
1
2
3
4
5
2. Please rate the impact of the above learning objectives on your professional competence
1
2
3
4
5
3. Please rate the impact of the above learning objectives on your professional performance :
1
2
3
4
5
4. Please rate the impact of the above learning objectives on your patient care outcomes :
1
2
3
4
5
5. A verbal or written statement regarding conflict of interest was made:
YES
NO
6. Do you feel that the speaker had any bias (commercial or other) that is relevant to this CME activity:
YES
NO
7. Estimate the likelihood that you will make changes in the care and management of your patients as result of this activity:
Not at all
Somewhat Likely
Highly Likely
Definitely
1
2
3
4
8. Please list at least 1 specific change in patient care you intend to make after participating in this activity?
9. Issues in Cultural and Linguistic Competency (e.g. differences in prevalence, diagnosis, treatment in
diverse population; linguistic skills; pertinent cultural date) were adequately addressed in this activity:
YES
NO
Please explain:
10. After attending this presentation, please suggest two topics for future educational activities:
Thank you for taking the time to complete this form!
s:medstf/cme/cme program eval form.doc/revised 2011
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Your comments are essential for improving the effectiveness of SCVMC continuing medical education activities. Please
complete this questionnaire and return it at the end of the activity.
TITLE:
DATE:
SPEAKER:
REVIEWER:
Educational Objectives:
1.
2.
3.
Please indicate how well this activity addressed the educational objectives:
Education
Very
Poor
Fair
Good
Excellent
Good
Objective
# 1
1
2
3
4
5
# 2
1
2
3
4
5
# 3
1
2
3
4
5
1. Please rate the effectiveness of the presentation (as above scoring):
1
2
3
4
5
2. Please rate the impact of the above learning objectives on your professional competence
1
2
3
4
5
3. Please rate the impact of the above learning objectives on your professional performance :
1
2
3
4
5
4. Please rate the impact of the above learning objectives on your patient care outcomes :
1
2
3
4
5
5. A verbal or written statement regarding conflict of interest was made:
YES
NO
6. Do you feel that the speaker had any bias (commercial or other) that is relevant to this CME activity:
YES
NO
7. Estimate the likelihood that you will make changes in the care and management of your patients as result of this activity:
Not at all
Somewhat Likely
Highly Likely
Definitely
1
2
3
4
8. Please list at least 1 specific change in patient care you intend to make after participating in this activity?
9. Issues in Cultural and Linguistic Competency (e.g. differences in prevalence, diagnosis, treatment in
diverse population; linguistic skills; pertinent cultural date) were adequately addressed in this activity:
YES
NO
Please explain:
10. After attending this presentation, please suggest two topics for future educational activities:
Thank you for taking the time to complete this form!
s:medstf/cme/cme program eval form.doc/revised 2011