Abstract
To receive CME credit, you must complete both this form and the evaluation form and return the completed forms to: The FCG Institute for Continuing Education-101013, 1140 Welsh Road, Suite 210, North Wales, PA 19454, or fax to 215-412-9686. A passing score of 70% or higher on the posttest is required to receive credit. A certificate will be mailed to you within 4 weeks of our receiving this form and the evaluation form.
1. The content level was: ____ Too easy ____ About right ____ Too difficult
6. Please rate the effectiveness of the presentation(s) in the following areas listed below.
Can you apply the information gained from this activity into your practice? ___Yes ___ No If no, please explain Do you feel that this activity was based on appropriate levels of evidence and currently accepted best practices? ___Yes ___ No Comments: Do you feel the activity was biased toward any commercial product, device, or treatment recommendations? ___Yes ___ No If yes, please explain_________________________________________________ _________________________________________________________________________ What was the most useful information you gained from this activity? _________________________________________________________________________ _________________________________________________________________________ Suggested topics for future activities: _________________________________________________________________________ _________________________________________________________________________ General comments/suggestions: _________________________________________________________________________ _________________________________________________________________________ How long did it take you to complete this activity? _____ hours _____ minutes
First Name, Middle Initial, Last Name:
__________________________________________________________________
Are you a US licensed physician? ___Yes ___No Specialty:______________________
Degree: MD DO PhD PharmD RPh NP RN Other_________
Complete Mailing Address:
__________________________________________________________________
City:_____ State:_____ Zip Code:_____
Business Phone:_____
E-mail Address:_____@_____
Number of CME hours participation CME (maximum 3.0):_____
How did you learn about this continuing education event?
Brochure/mail E-mail Internet Colleague recommended Other_____
What formats do you prefer for learning (Please rank the top 3):
Other___________________________
Signature:_______________ Date:_______________
Thank you for your feedback. Your comments will be reviewed carefully and ultimately used to guide the development and implementation of our future continuing education activities.