Tufts Medicine Lowell _ Program Evaluation

Continuing Education Program Evaluation
Program Title*
ACCME Number*
Credit*
Category*
BORIM Credit*
Format*
Participant Information

Required for credit reporting.
First Name*
Last Name*
Email*
example@example.com
Site*
Degree*

Participant Information

Required for credit reporting.
Date of Birth (MM/DD only — do not include year)
Massachusetts License Number
Are you requesting submission of CME credit for Maintenance of Certification (MOC) to one of the following certifying boards? ABIM, ABP, ABS, or ABPath

YesNo

Maintenance of Certification (MOC) – Board Upload

CME credit submission is available only for the following certifying boards: ABIM, ABP, ABS, and ABPath.

Important: If you do not know your board certification number, please click Back and select “No” for MOC submission.
Select Your Board

ABIMABSABPABPath
Board Certification Number (as listed with your board)

Practice Impact

The following questions help us assess how this activity may influence your clinical practice and are required for CME credit.
As a result of this activity, I intend to improve:*

Diagnostic EvaluationTherapeutic ApproachesSurgical TechniqueCommunication SkillsUse of InformaticsEvidence-Based PracticePatient SafetyPractice Performance
Please list TWO new insights or concepts you gained from this activity.*

Additional Feedback (Optional)

Your feedback is appreciated and helps us improve future educational activities.
Speaker Knowledge

5 = Excellent
Program Comments
Future Topic/Speaker Requests
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