University of Kansas Department of Ophthalmology
Continuing Medical Education Evaluation & Credit Claim
Which activity did you attend?
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KU Eye Ophthalmology Grand Round
KU Eye Research Grand Round
Date of activity
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-
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?
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Rate your confidence in applying your new learning into practice:
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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
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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:
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Rows
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?
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MD
Other
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Physicians
MD/DO
Name
*
First Name
Last Name
Credentials (as you want them to appear on your certificate)
*
Email address for Continuing Medcial Education tracking
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example@example.com
Number of Continuing Medical Education credits you are claiming:
*
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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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