University Health RSS
Continuing Medical Education Evaluation & Credit Claims
Which activity did you attend?
Breast Tumor Case Conference
Emergency Department Case Conference
Emergency Department Faculty Development RSS
Emergency Department Journal Club
Emergency Department M&M
Emergency Department/Internal Medicine M&M
Family Medicine RSS
Multidisciplinary GI Tumor Case Conference
Multidisciplinary Trauma Course (MTC) Grand Round
Multidisciplinary Tumor Case Conference
Ophthalmology RSS Core/GR
Ophthalmology RSS JC
Trauma M&M
Date of activity
-
Month
-
Day
Year
Date
Do you want to evaluate and claim credit for another activity?
Yes
No
Which activity did you attend?
Breast Tumor Case Conference
Emergency Department Case Conference
Emergency Department Faculty Development RSS
Emergency Department Journal Club
Emergency Department M&M
Emergency Department/Internal Medicine M&M
Family Medicine RSS
Medicine Grand Rounds
Multidisciplinary GI Tumor Case Conference
Multidisciplinary Trauma Course (MTC) Grand Round
Multidisciplinary Tumor Case Conference
Ophthalmology RSS
Trauma M&M
Date of activity
-
Month
-
Day
Year
Date
Do you want to evaluate and claim credit for another activity?
Yes
No
Which activity did you attend?
Breast Tumor Case Conference
Emergency Department Case Conference
Emergency Department Faculty Development RSS
Emergency Department Journal Club
Emergency Department M&M
Emergency Department/Internal Medicine M&M
Family Medicine RSS
Medicine Grand Rounds
Multidisciplinary GI Tumor Case Conference
Multidisciplinary Trauma Course (MTC) Grand Round
Multidisciplinary Tumor Case Conference
Ophthalmology RSS
Trauma M&M
Date of activity
-
Month
-
Day
Year
Date
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What changes do you plan to make in your practice as a result of participating in this activity?
*
Rate your confidence in applying your new learning into practice:
*
1
2
3
4
5
Not confident
Confident
1 is Not confident, 5 is Confident
What barriers to implementing changes do you experience in your practice? Check all that apply.
Cost constraints
Insurance/Reimbursement issues
Lack of time with patients
Overwhelming amount of information
Lack of administrative or management support, workflow issues
Lack of authority to implement changes
Gaps in my knowledge and training
Lack of support staff
Gaps in support staff knowledge and training
I do not anticipate any barriers to implementing changes
Other
Did you detect any ACCME defined commercial interest bias in this activity?
*
Yes, commercial interest bias
No
If yes, to the above question please describe
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What areas of your practice could be enhanced or improved with additional education?
Please indicate your level of agreement with the following statements:
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The speaker(s) were effective at presenting the content
The information presented is relevant to my clinical practice
This activity will improve my ability to care for patients
This activity will improve patient outcomes
This activity increased my competence of the subject matter
The educational format was appropriate for the setting, objectives, and desired results of this activity
What are your credentials?
*
MD/DO
Other
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Physicians
MD/DO
Number of Continuing Medical Education credits you are claiming:
Name
First Name
Last Name
Credentials (as you want them to appear on your certificate)
Email address for CME tracking
example@example.com
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Non-Physician
Certificate of Completion
Name
First Name
Last Name
Credentials (as you want them to appear on your certificate):
Email
example@example.com
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Submit
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