[TITLE OF ACTIVITY]
[LOCATION OF ACTIVITY]
[DATE OF ACTIVITY]
OUTCOMES MEASUREMENT
The ACCME (Accreditation Council for Continuing Medical Education) has updated its criteria for CME providers to
be accredited, and compliance with the Updated Criteria includes a component in which changes in physician
competence, performance, or patient outcomes are measured.
Please identify one or two specific changes that you plan to implement in your professional practice as a result
of information you obtained as an attendee at this CME activity.
1. __________________________________________________________________________________
2. __________________________________________________________________________________
A staff member in the University of Florida CME Office will contact you approx. 12 to 15 weeks following the
activity to briefly follow-up on the status of the change(s) you planned to implement in your practice. You will be
asked to identify your level of confidence in implementing intended changes in your clinical practice and/or
implementing techniques/skills you learned, and to identify any barriers you encountered (time or staffing
constraints, lack of resources, need for more direction/instruction, etc.). Please complete the requested
information below to indicate your preferred method of contact.
Print Name_____________________________ Signature_______________________________
I prefer to be contacted by the following method(s), as indicated: (Circle preference of method to be contacted):
 phone #
First
Second
Third
 fax #
First
Second
Third
 email
First
Second
Third
Please return completed form to Registration Desk, or to
UF Continuing Medical Education, PO Box 100233, Gainesville FL 32610-0233
Phone: 352-733-0064
Fax: 352-733-0007
email: cme-mail.ufl.edu