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Project ECHO: Evaluation and CME/CE Credit Claim Form
Date
*
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Year
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Your Information
Name
*
First Name
*
Last Name
*
Which of the following best describes you?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino or Spanish Origin
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
What is your gender identity?
Female
Male
Non-binary
Prefer not to answer
Other:
Other Value
Credential
*
MD/DO
APRN
PA
RN
MA (Medical Assistant)
LVN
PhD
PharmD
CHW
Other:
Other Value
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Email
*
Phone
License Number
*
Verification of Attendance
I attest that participated in this activity
*
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Course Evaluation
As a result of my participation in this CME activity:
*
As a result of my participation in this CME activity:
Strongly Agree
Agree
Unsure
Disagree
Strongly Disagree
My knowledge increased
As a result of my participation in this CME activity:: My knowledge increased (Strongly Agree)
My knowledge increased (Agree)
My knowledge increased (Unsure)
My knowledge increased (Disagree)
My knowledge increased (Strongly Disagree)
My ability to provide appropriate care to my patients improved
My ability to provide appropriate care to my patients improved (Strongly Agree)
My ability to provide appropriate care to my patients improved (Agree)
My ability to provide appropriate care to my patients improved (Unsure)
My ability to provide appropriate care to my patients improved (Disagree)
My ability to provide appropriate care to my patients improved (Strongly Disagree)
I will make changes in my practice
I will make changes in my practice (Strongly Agree)
I will make changes in my practice (Agree)
I will make changes in my practice (Unsure)
I will make changes in my practice (Disagree)
I will make changes in my practice (Strongly Disagree)
I feel a decreased sense of professional isolation
I feel a decreased sense of professional isolation (Strongly Agree)
I feel a decreased sense of professional isolation (Agree)
I feel a decreased sense of professional isolation (Unsure)
I feel a decreased sense of professional isolation (Disagree)
I feel a decreased sense of professional isolation (Strongly Disagree)
Please rate your overall satisfaction with this clinic session:
*
Please rate your overall satisfaction with this clinic session:
Very Satisfied
Satisfied
Neutral
Dissastisfied
Very Dissastisfied
Televideo connection
Please rate your overall satisfaction with this clinic session:: Televideo connection (Very Satisfied)
Televideo connection (Satisfied)
Televideo connection (Neutral)
Televideo connection (Dissastisfied)
Televideo connection (Very Dissastisfied)
Information provided
Information provided (Very Satisfied)
Information provided (Satisfied)
Information provided (Neutral)
Information provided (Dissastisfied)
Information provided (Very Dissastisfied)
Time for questions/answers
Time for questions/answers (Very Satisfied)
Time for questions/answers (Satisfied)
Time for questions/answers (Neutral)
Time for questions/answers (Dissastisfied)
Time for questions/answers (Very Dissastisfied)
Relevance to your practice
Relevance to your practice (Very Satisfied)
Relevance to your practice (Satisfied)
Relevance to your practice (Neutral)
Relevance to your practice (Dissastisfied)
Relevance to your practice (Very Dissastisfied)
If you plan to make changes in your practice, please identify any barriers that you perceive in implementing these changes (select all that apply):
Lack of time to assess patients
Lack of time to counsel patients
Insurance/Reimbursement issues
Patient compliance issues
Lack of consensus on professional guidelines
Lack of knowledge to do so
Lack of management/clinic support
None – I do not plan to make any changes
None – I am able and plan to make changes
Other
Other, please explain
Was the material presented in a manner that was free from commercial bias?
Yes
No
If no, please explain:
Please list topics of future interest and additional comments regarding teleECHO programs:
Would you be interested in participating in a formal evaluation of Project ECHO?
Yes
No
If yes, please provide your email address:
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