University of Maryland School of Medicine FY2010 CME LIVE ACTIVITY EVALUATION Activity Title: Activity Date: Activity Location: Section I : Learner Information 1. My professional category/degree is: MD/DO—in practice MD/DO—Resident/Fellow Sonographer
Nurse Specialist (e.g., CRNA, NP) Nurse (e.g., RN, LVN) PhD/PsyD/EdD/DrPH
PAC Genetic Counselor Other (specify) _________________
2. My occupation/specialty is: ________________________________________________ 3. My practice setting is best described as:
4. Number of years in practice:
Office/Community
Less than 5 years 6 – 10 years 11 – 15 years 16 – 25 years Other ___________________________
Academic Setting/University/Teaching Other (specify) _________________________
Section I: Speaker Ratings Please rate the effectiveness of each speaker, on a scale of 1 to 5 where 1 = poor and 5 = excellent. Provide an explanation or suggestion for improvement in areas rated three or lower. Poor → Excellent Presentation/Topic
1
2
3
4
5
Explanation/Suggestions for Improvement
<day of the week, month date, year> Session Title – Presenter, degree Session Title – Presenter, degree Session Title – Presenter, degree
Live CME Activity Evaluation – Revised September 2009
Page 1 of 3
Section II: Achievement of Educational Objectives Please rate your level of agreement with the following statements (1 = strongly disagree; 5 = strongly agree).
Strongly Disagree
At the conclusion of this activity, participants should be able to describe and discuss: Current capabilities of prenatal diagnosis The disease specific role of specific prenatal examination techniques Indications and techniques of fetal surveillance Indications and capabilities of fetal therapy
1
Strongly → Agree 2
3
4
5
Please explain
Section III: Application in Practice Please rate your level of agreement with the following statements (1 = strongly disagree; 5 = strongly agree).
Strongly Disagree 1
2
Strongly → Agree 3
4
5
Please explain
The activity content will assist me in enhancing patient care. Activity helped translate basic/clinical research data into practical applications. The information provided has motivated me to modify my practice behavior. Will you make any changes in your practice as a result of the program? Yes No Not Applicable If yes, please explain/provide an example; if no, explain why not: _____________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Section III: Balance and Objectivity Please rate your level of agreement with the following statements (1 = strongly disagree; 5 = strongly agree).
Strongly Disagree 1
2
Strongly → Agree 3
4
5
Please explain
The content was objective, balanced and scientifically rigorous. The activity content promoted improvements/quality in healthcare and Live CME Activity Evaluation – Revised September 2009
Page 2 of 3
not proprietary commercial interests. Was the activity content was free of commercial bias: Agree
Disagree
If disagree, please explain ______________________________________________________________________ ___________________________________________________________________________________________
Section III: Program Assessment and Improvement Please rate your level of agreement with the following statements (1 = strongly disagree; 5 = strongly agree).
Strongly Disagree 1
2
Strongly → Agree 3
4
5
Please explain
The physical facilities were suitable for the activity. The program coordination and staff were efficient and responsive. What was your overall appraisal of the program?
Poor
Fair
Would you recommend this program to others?
Yes
No
Good
Excellent
What were this activity’s strengths?
a) ________________________________________________________________________________________ b) ________________________________________________________________________________________ What were this activity’s weaknesses?
a) ________________________________________________________________________________________ b) ________________________________________________________________________________________ What topics would you like to see addressed in future CME activities?
a) ________________________________________________________________________________________ b) ________________________________________________________________________________________ c) ________________________________________________________________________________________
Live CME Activity Evaluation – Revised September 2009
Page 3 of 3