JP Evaluation template

Quality of Instruction *

	Poor	Fair	Good	Excellent
Learning Objectives were met	Learning Objectives were met - Poor	Learning Objectives were met - Fair	Learning Objectives were met - Good	Learning Objectives were met - Excellent
Quality of the Content	Quality of the Content - Poor	Quality of the Content - Fair	Quality of the Content - Good	Quality of the Content - Excellent
Quality of Presentation	Quality of Presentation - Poor	Quality of Presentation - Fair	Quality of Presentation - Good	Quality of Presentation - Excellent
Scientific Integrity	Scientific Integrity - Poor	Scientific Integrity - Fair	Scientific Integrity - Good	Scientific Integrity - Excellent
Held My Interest	Held My Interest - Poor	Held My Interest - Fair	Held My Interest - Good	Held My Interest - Excellent
Relevant to My Practice	Relevant to My Practice - Poor	Relevant to My Practice - Fair	Relevant to My Practice - Good	Relevant to My Practice - Excellent
Appropriate Level of Difficulty	Appropriate Level of Difficulty - Poor	Appropriate Level of Difficulty - Fair	Appropriate Level of Difficulty - Good	Appropriate Level of Difficulty - Excellent
Increased my confidence in managing clinical or professional issues	Increased my confidence in managing clinical or professional issues - Poor	Increased my confidence in managing clinical or professional issues - Fair	Increased my confidence in managing clinical or professional issues - Good	Increased my confidence in managing clinical or professional issues - Excellent
Worth My Time	Worth My Time - Poor	Worth My Time - Fair	Worth My Time - Good	Worth My Time - Excellent
Overall Rating	Overall Rating - Poor	Overall Rating - Fair	Overall Rating - Good	Overall Rating - Excellent
My Recommendation to Colleagues	My Recommendation to Colleagues - Poor	My Recommendation to Colleagues - Fair	My Recommendation to Colleagues - Good	My Recommendation to Colleagues - Excellent

Did any of the speakers have commercial bias? *

Yes

No

Please provide more detail about the bias observed *

Did the speaker(s) properly disclose relevant financial relationships (name of commercial interest and nature of the relationship) or state that they had nothing to disclose? *

Yes

No

Please explain *

Was any off-label (investigational/experimental) use discussed? *

Yes

No

Was this disclosed to the learners? *

Yes

No

Please identify the speaker and explain *

Based on the content of this session/activity, what will you do differently in the care of your patients? *

Implement a change in my practice

Seek additional information on this topic

Do nothing differently. Current practice reflects activity recommendations.

Do nothing differently as the content was not convincing.

Do nothing differently; primary barriers prevent me from changing my practice.

Not applicable. I do not see patients with the condition discussed or I do not see patients in my current position.

If you plan to implement a change(s) in your practice, please identify what that change(s) will be. *

Please indicate the primary barriers preventing change *

Lack of evidence-based guidelines

Lack of applicability of guidelines to my current practice/patients

Lack of time

Insurance/Financial

Organizational/Institutional

Patient adherence/Compliance

Treatment related to adverse events

Not applicable. I don't see patients with the condition discussed or I don't see patients in my current position.

Other...

Please indicate the primary barriers preventing change Other...

Based on educational needs, please provide healthcare or professional gaps that should be addressed in future educational activities and that may be applicable to your practice

Please describe any ways we might improve this educational activity

Was there any speaker that stood out as exceptional?

Was there any speaker that may need some improvement?

Additional comments

How many years have you been in practice? *

0-5 years

6-10 years

11-15 years

More than 15 years

How many patients do you manage weekly? *

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