Surgical Education Week Evaluation Form ASE/APDS | 2017 Surgical Education Week April 18-22, 2017 | San Diego, CA Name* First Last Credentials (ex. MD, DO)* Email* ARE YOU A MEMBER OF THE AMERICAN COLLEGE OF SURGEONS?* Yes No WHAT IS YOUR ACS MEMBERSHIP ID (required)* Credits will not post to your ACS MyCME webpage if ID not provided WHICH MEETING DID YOU ATTEND DURING SURICAL EDUCATION WEEK?* ASE Meeting Only APDS Meeting Only BOTH ASE Meeting and APDS Meeting AS A PARTICIPANT OF THIS ACTIVITY, HOW MANY HOURS ARE YOU CLAIMING OF CME CREDIT OUT OF 17.5? Please note that you must claim in increments of.25*Please enter a number from 0 to 17.5.AMA PRA Category 1 Credits™ The American College of Surgeons designates this live activity for a maximum of 17.5AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. *NOTE: 15 MINUTES OF SESSION ATTENDANCE = 0.25 AMA PRA CATEGORY 1 CREDITS™AS A PARTICIPANT OF THIS ACTIVITY, HOW MANY HOURS ARE YOU CLAIMING OF CME CREDIT OUT OF 18.25? Please note that you must claim in increments of.25*Please enter a number from 0 to 18.25.AMA PRA Category 1 Credits™ The American College of Surgeons designates this live activity for a maximum of 18.25AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. *NOTE: 15 MINUTES OF SESSION ATTENDANCE = 0.25 AMA PRA CATEGORY 1 CREDITS™AS A PARTICIPANT OF THIS ACTIVITY, HOW MANY HOURS ARE YOU CLAIMING OF CME CREDIT OUT OF 35.75? Please note that you must claim in increments of.25*Please enter a number from 0 to 35.75.AMA PRA Category 1 Credits™ The American College of Surgeons designates this live activity for a maximum of 35.75AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. *NOTE: 15 MINUTES OF SESSION ATTENDANCE = 0.25 AMA PRA CATEGORY 1 CREDITS™1. Overall, how would you rate this educational activity?* 5 Excellent 4 Very Good 3 Good 2 Fair 1 Poor 2. Program topics and content met the stated objectives.* 5 Excellent 4 Very Good 3 Good 2 Fair 1 Poor 3. Content was relevant to my educational needs.* 5 Excellent 4 Very Good 3 Good 2 Fair 1 Poor 4. Educational format was conducive to learning.* 5 Excellent 4 Very Good 3 Good 2 Fair 1 Poor 5. Acquired knowledge will be applied in my practice environment.* 5 Excellent 4 Very Good 3 Good 2 Fair 1 Poor 6. I will seek additional information on this subject.* 5 Excellent 4 Very Good 3 Good 2 Fair 1 Poor 7. Program was fair, objective, and unbiased toward any product or program* 5 Excellent 4 Very Good 3 Good 2 Fair 1 Poor 8. Please explain any specific instance(s) of bias or conflict of interest.*9. List a minimum of two things you are going to change in your practice as a result of what you have learned at this activity.*10. Describe the barriers anticipated when implementing the above changes.*11. Do you have any suggestions for future topics to support and/or expand on what you have learned at this activity?*12. Additional Comments
