School of Medicine Office of Continuing Professional Development & Evaluation Studies

Title here --

Date, 2009 Location FAX

Phone (804) 828-3640 (804) 828-7438

All evaluation responses are confidential. We would like to send a follow-up questionnaire in about 60 days. Email address please: ___________________________________________________ 1. Please rate the following: 4=Agree 5=Strongly Agree 1=Strongly Disagree 2=Disagree 3=Neutral

a. The material was organized clearly to facilitate 1 2 3 4 5 learning b. Content will enhance my practice 1 2 3 4 5 c. Information provided will improve my patient 1 2 3 4 5 outcomes d. Content was free of commercial bias or influence 1 2 3 4 5 e. This presentation format facilitated my learning 1 2 3 4 5 f. Overall, this learning activity met the educational 1 2 3 4 5 objectives If you indicated in 1d above that there was commercial influence, please describe: _____________________________________________________________________________________________ 2. As a result of participating in this session, will you make changes in your practice? (Circle one) Yes (go to question #3) No (go to question #6) Uncertain (go to question #7) 3. If Yes, please specify one change you will make in your practice :

4. Please circle your level of commitment in implementing this change: Lowest 1 2 3 4 5

Highest

5. Please circle your level of confidence in implementing this change: Lowest 1 2 3 4 5 Highest Now, go to question #8 6. If you answered No to question #2, please explain why you will make no change following this session: 7. If you answered Uncertain to question #2, please describe the reason for your uncertainty:

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8. Please describe how this educational program may improve your patient outcomes: 9. Demographics: a. Gender: M F b. Age: 20 29 30 39 40 49 50 59 c. Number of years in practice: ____________ d. Degree(s) and certification(s): ______________________________________________________________ e. Clinical specialty: ________________________________________________________________________ Overall Goals of this Educational Activity: 1. 2. 3. 4. Confidence Rating (create from overall educational goals) 10. With 1 being very low and 5 being very high, for each item below, please rate your confidence before and after this training from 1 to 5:
Very Low Confidence

60 or older

Low Confidence

Neutral High Confidence

Very High Confidence

Before training a. Ability to improve patient outcomes [sample] b. Management of [sample objective] c. Assessment and outcome measurement of d. Clinical guidelines [sample] e. Teaching strategies [sample objective] 11. Please rate the following concurrent sessions: (5=Highest) Day, Month, 2009 Session I: Topic Day, time Presenter: Title Objective: Describe Usefulness of content Presentation skills Objective achieved Objective: Explain Usefulness of content Presentation skills Objective achieved Presenter: Title 1 1 1 2 2 2 3 3 3 1 1 1 2 2 2 3 3 3

After training

4 4 4 4 4 4

5 5 5 5 5 5

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12. Why did you choose to participate in this learning activity?

13. Please share suggestions to improve this learning activity:

Thank you!