Activity Title:
Activity Location:
Responsible Organization:
Director / Administrator:
Activity Date:
CME FORM 108
PLEASE COMPLETE THIS EVALUATION SUMMARY AFTER EACH CME ACTIVITY AND SUBMIT IT WITH THE
CME FORM 105 CLOSING REPORT TO THE UHMS HOME OFFICE CME COORDINATOR.
ENTER THE NUMBER OF TOTAL RESPONSES INDICATED. A PERCENTAGE MAY BE USED IF YOU PREFER
1. This session has increased, improved, or positively impacted my: (select all that apply)
O Knowledge
________ respondents
O Competence
________ respondents
O Performance
________ respondents
O Patient Outcomes
________ respondents
O No Change
________ respondents
2. This activity is free of commercial bias* or influence?
O Yes
________ respondents
O No
________ respondents
If any respondents answered yes, please list comments for the Subcommittee on CME Effectiveness to review:
3. The overall objective was met
O Yes
________ respondents
O No
________ respondents
4. This activity met my educational needs
O Yes
________ respondents
O No
________ respondents
5. The references were appropriate
O Yes
________ respondents
O No
________ respondents
6. The educational format(s) is appropriate for the setting, objective, and desired result
O Yes
________ respondents
O No
________ respondents
7. The content matches my current or potential scope of professional activities
O Yes
________ respondents
O No
________ respondents
8. This activity has addressed competencies that are applicable with the following: (select all that apply):
O Patient care or patient-centered care
________ respondents
O Interpersonal and communication skills ________ respondents
O Practice-based learning & improvement ________ respondents
O Professionalism
________ respondents
O System-based practice
________ respondents
O Interdisciplinary teams
________ respondents
O Quality improvement
________ respondents
O Utilize informatics
________ respondents
O Medical knowledge
________ respondents
O Employ evidence-based practice
________ respondents
O None of the above
________ respondents
9. How will you change your practice as a result of attending this session (select all that apply)?
O Create/revise protocols, policies, and/or procedures
CME Form 108 Evaluation Summary
________ respondents
O Change the management and/or treatment of my patients
O This activity validated my current practice
O I will not make any changes to my practice because
O Other, please specify:
________ respondents
________ respondents
________ respondents
________ respondents
10. Please indicate any barriers you perceive for implementing these changes.
O Cost
________ respondents
O Lack of experience
________ respondents
O Lack of opportunity (patients)
________ respondents
O Lack of resources (equipment)
________ respondents
O Lack of administrative support
________ respondents
O Lack of time to assess/counsel patients
________ respondents
O Reimbursement/insurance issues
________ respondents
O Patient compliance issues
________ respondents
O Lack of consensus or professional guidelines
________ respondents
O No barriers
________ respondents
O Other
________ respondents
11. How will you address these barriers to implement changes in knowledge and/or behavior?
Please list any responses
12. What changes might be made in the overall format of this CME activity in order to be the most appropriate
for the content presented (select all that apply)?
O Format is appropriate; no changes needed
________ respondents
O Add a hands-on instructional component
________ respondents
O Include more case-based presentations
________ respondents
O Schedule more time for Q and A
________ respondents
O Increase interactivity with attendees
________ respondents
O Other
________ respondents
Put a check in the box to indicate the average response rating the speakers. If you have your own ranking
scale for speakers of this activity please submit the average score relating to your own speaker evaluation.
14. Speaker(s) (Overall)
Excellent
Above
Average
Average
Below
Average
Poor
Overall Presentation
Organized Presentation: clearly presented and
explained concepts
Useful, relevant & practical information
Comments: Please type up any relevant comments that will be effective in planning and implementing future
CME activities:
TOTAL # OF RESPONDENTS FOR THIS CME ACTIVITY
CME Form 108 Evaluation Summary
TOTAL # OF REGISTRANTS FOR THIS CME ACTIVITY