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School of MedicineOffice of Continuing Professional Development & Evaluation Studies

Title here -- Date, 2009 LocationPhone (804) 828-3640 FAX

(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: 1=Strongly Disagree 2=Disagree 3=Neutral4=Agree 5=Strongly Agree

a.The material was organized clearly to facilitatelearning

1 2 3 4 5

b. Content will enhance my practice 1 2 3 4 5c. Information provided will improve my patientoutcomes

1 2 3 4 5

d. Content was free of commercial bias or influence 1 2 3 4 5e. This presentation format facilitated my learning 1 2 3 4 5f. Overall, this learning activity met the educationalobjectives

1 2 3 4 5

If you indicated in 1d above that there was commercial influence, pleasedescribe:_____________________________________________________________________________________________

2. As a result of participating in this session, will you make changes in your practice? (Circleone)

Yes (go to question #3) No (go to question #6) Uncertain(go to question #7)

3. IfYes, please specify onechange you will make in your practice :

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

5. Please circle your level ofconfidence 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 changefollowing this session:

7. If you answered Uncertain to question #2, please describe the reason for youruncertainty:

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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 60 or older

c. Number of years in practice: ____________d. Degree(s) and certification(s):

______________________________________________________________

e. Clinical specialty:

________________________________________________________________________

Overall Goals of this EducationalActivity:

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 yourconfidence beforeandafter

this training from 1 to 5:

1 2 3 4 5 Very Low Low Neutral High Very High

Confidence Confidence Confidence Confidence

Before

training

After

traininga. 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: TopicDay, time

Presenter: TitleObjective: Describe

Usefulness of content 1 2 3 4 5Presentation skills 1 2 3 4 5Objective achieved 1 2 3 4 5

Presenter: TitleObjective: Explain Usefulness of content 1 2 3 4 5Presentation skills 1 2 3 4 5Objective achieved 1 2 3 4 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!