For CME (MD, DO, NP, PA, Physics (self-reporting)), CEU (RN), MDCB credits only
Activity Evaluation Form
Activity Date:
February 3, 2016-February 2,
2017
Activity Title:
Multiple Brain Metastases & Volumetric Modulated Arc Radiosurgery: Refining the Single-Isocenter
Technique to Benefit Surgeons & Patients
Activity Objective(s):





# Designated Credits:
CME #:
1.0
868
At the conclusion of the program, participants will be able to:
Understand the evolving role of radiosurgery in the treatment of more than four brain metastases
Describe the risks and benefits of whole brain radiation therapy
Compare and contrast various delivery methods of radiosurgery for multiple targets
Describe optimal treatment planning strategies for single isocenter VMAT radiosurgery
List the patient and programmatic benefits of frameless flattening-filter free radiosurgery
Complete this form at the conclusion of today’s educational activity, and return it to the registration desk.
Did this activity meet the stated objectives?
Yes
No
Did this activity convey information that will assist you in improving the health of your patients?
Yes
No
Was potential faculty conflict-of-interest (disclosure) conveyed to the audience prior to the activity?
Yes
No
Rate the following on a scale of 1 (Poor) to 5 (Excellent).
Poor
1
2
3
Conference Materials/Handouts
1
2
3
Room Set-Up
1
2
3
Audio-Visuals
How did you hear about this conference?
Excellent
5
5
5
4
4
4
Brochure
Colleague
Overall Program Evaluation
Please rate the overall impact of this educational activity on your:
Knowledge
Competence
Patient Care Processes
Poor
1
1
1
2
2
2
3
3
3
4
4
4
Excellent
5
5
5
Website
Other
Please rate the overall impact of the course objectives on your:
Knowledge
Competence
Patient Outcomes
Poor
1
1
1
2
2
2
3
3
3
4
4
4
Excellent
5
5
5
Please assess how well this activity met your identified educational needs and practice gaps:
Poor
1
2
3
4
Excellent
5
Excellent
5
5
5
Please rate the following aspects of this educational activity:
Overall quality
Selection of topics
Quality of faculty
Activity Organization
Questions and Discussion
Relevance to Practice
Poor
1
1
1
2
2
2
3
3
3
4
4
4
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
Please estimate the likelihood that you will make changes in the care and the management of your patients as a
result of this CME activity (circle one):
No
1
2
3
4
Definitely
5
Based on your participation in this CME activity do you anticipate any of the following changes?
Modify your management of multiple brain metastases?
Yes
No
Consider the use of VMAT in the treatment of brain metastases?
Yes
No
Make changes to treatment planning for multiple brain metastases?
Yes
No
Implement any changes to increase patient safety and comfort?
Yes
No
Please list any other changes in patient care you anticipate from a result of this activity:
Please identify any barriers you perceive in implementing these changes (circle all that apply):
a. Cost
b. Lack of time to assess/counsel patients
c. Lack of administrative support/resources
d. Patients compliance issues
e. Lack of consensus or professional guidelines
f. Other (describe)
Issue in cultural and linguistic competency (e.g. differences in prevalence, diagnosis, treatment, linguistic skills
in diverse populations) were adequately addressed:
YES
NO (Why)
Do you feel that the addition of CME credits to this program provided added value and credibility?:
YES
NO
Based on your identified educational needs and/or professional practice gaps, please provide us with
suggestions for future program topics and formats.
Please rate the quality of the Program Faculty’s presentation on a scale of 1 (Poor) to 5 (Excellent) and indicate if
the presentation was well balanced and free from commercial bias for or against any product or company.
Overall Presentation
Poor
Excellent
Presentation was
Fair & Balanced &
Free From Bias
Faculty Name:
Presentation Title
John Fiveash, MD
“Multiple Brain Metastases & Volumetric
Modulated Arc Radiosurgery: Refining the
Single-Isocenter Technique to Benefit
Surgeons & Patients”
1
2
3
4
5
Yes
No
Evan Thomas, MD, PhD
“Multiple Brain Metastases & Volumetric
Modulated Arc Radiosurgery: Refining the
Single-Isocenter Technique to Benefit
Surgeons & Patients”
1
2
3
4
5
Yes
No
Comments:
Your
Professional
Degree
(MD/DO/RN):
Your
Specialty (ie:
radiation
onology):
Please print
clearly: Name
& Email:
Zip code:
*Please note that any reissue of a certificate will incur a $20 reissuance fee.*
Please return this evaluation and post-test form via email to: contact@ime-cme.com or by
fax to (310) 689-7272