SIGN IN SHEET
Optimizing Long-term Care of Patients with Dementia
PLEASE FAX THIS SHEET TO 1-908-281-2021 or scan and send to Jnaqvi@PGELTC.org
THE ACCREDITATION REQUEST HAS TO BE SENT TO sjones@cmepartner.org
IMPORTANT Each participant must complete the evaluation form below and send it as specified.
NAME
Last Name, First
Date
EMAIL ADDRESS
Facility Name
Optional
EVALUATION FORM
Optimizing Long-term Care of Patients with Dementia
Medical Education Resources and NADONA/LTC respect and appreciate your opinions. To assist us in
evaluating the effectiveness of this activity and to make recommendations for future educational offerings,
please take a few minutes to complete this evaluation form.
If you wish to receive acknowledgement of participation for this activity, please PRINT in your
contact information and return this form:
MER
Attn: Susan Jones
9785 Maroon Circle, Suite 100
Englewood, CO 80112
Scan and Email to sjones@cmepartner.org
Or, you can fax the evaluations to 720.449.0217.
Name
Degree
MD DO PA RN NP RPh PharmD
RD Other ______
Pharmacists Only
Month and Date of Birth (MMDD)
Pharmacists Only
NABP ePID#
Organization
Address:
□ Hospital/Academic/Office
□ Home
City
State
Zip
Telephone
Fax
Email
I certify my actual time spent to complete this educational activity to be:
 I participated in the entire activity and claim 1 credit.
 I participated in only part of the activity and claim _____ credits.
Please answer the following questions by circling the appropriate rating:
5 = Outstanding
4 = Good
3 = Satisfactory
2 = Fair
Extent to Which Program Activities Met the Identified Objectives
After completing this activity, participants should be able to:
 Understand current requirements and society guidelines for
identifying new cases of AD during annual wellness visits of senior
patients. the potential of currently available pharmacologic and
 Recognize
 behavioral interventions for mitigating consequences of AD on
patients and caregivers.
 Explain the relative benefits and risks of concomitant treatment of
AD patients with antihypertensives, antidepressants and/or
 antipsychotics
Outline sources of ongoing psychological and behavioral support in

the community for AD patients and their caregivers.
Describe options for improving long-term care coordination for AD
patients through multidisciplinary teams, and opportunities for these
patients to participate in clinical trials on emerging therapies
1 = Poor
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1

Please indicate if this activity was free from commercial bias.
 Yes
 No
If No, please indicate the topic(s) that were not free from commercial bias.
____________________________________________________________________________________
_____________
Effectiveness of the Individual Faculty Members
Speakers
Knowledge of
Subject Matter
Richard Stefanacci, DO,
5 4 3 2 1
MGH, MBA, AGSF, CMD
Sherrie Dornberger, RNC,
5 4 3 2 1
CDONA, FACDONA
Effective in
Presenting Material
5 4 3 2 1
5
4
3
2
Avoided Commercial Bias or
Influence
5 4 3 2 1
1
5
4
3
2
1
Is there anything you would like to communicate directly to the speaker(s)?
____________________________________________________________________________________
_____________
Effectiveness of the CME content
 Content addressed the learning goal (purpose)
5
4
3
2
1
4
3
2
1

Enhanced my current knowledge base
5

Will help me improve patient care
5
4
3
2
1


Provided educational material that I found useful
5
4
3
2
1
Information was relevant to my practice and my educational
needs
Provided appropriate learning assessment activities
Provided effective teaching and learning methods, including
active learning
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1


Please indicate any changes you plan to make in your practice of medicine as a result of information you
received from this activity.
____________________________________________________________________________________
_____________
Please rate your commitment level to making these changes.
5
4
3
2
1
In what time frame do you anticipate making these changes?
 Immediately  1 -2 months  3 -6 months  At some point in the future
This activity was designed to help the participant master the
ABMS/ACGME core competences: patient care and medical
knowledge. How well did this activity address these
competencies?
5
4
3
2
1
Please provide general comments regarding this activity and suggest how it might be improved:
____________________________________________________________________________________
Are future educational activities on this topic needed?
 Yes
 No
Please indicate medical topics that would be of interest to you:
____________________________________________________________________________________
Medical Education Resources, Inc. 9785 S. Maroon Circle, Suite100, Englewood, Colorado 80112
Phone: 303-798-9682 Fax: 720-449-0217