UAMS Evaluation Form Step 1 of 6 16% Name of ActivityDate of Activity MM slash DD slash YYYY UAMS Employee? Yes No Profession Nurse APRN/NP PA Pharmacist Physician Other Practice Type Clinical Research Administration Teaching Other Practice Setting Private Hospital Community Hospital Private Practice Academic Health Center Other Please rate the impact of the following objectives: As a result of attending this activity, I am better able to:Objective 1Objective 1 Rating Strongly Agree Agree Neutral Disagree Strongly Disagree Objective 2Objective 2 Rating Strongly Agree Agree Neutral Disagree Strongly Disagree Objective 3Objective 3 Rating Strongly Agree Agree Neutral Disagree Strongly Disagree This field is hidden when viewing the formObjective 4This field is hidden when viewing the formObjective 4 Rating Strongly Agree Agree Neutral Disagree Strongly Disagree I work as a member of a health care team Yes No Unsure As a result of attending this activity:I intend to apply the knowledge and/or skills I have acquired from this activity to my work when in a team environment. Strongly Agree Agree Neutral Disagree Strongly Disagree Not Applicable I am better able to collaborate with a multidisciplinary team. Strongly Agree Agree Neutral Disagree Strongly Disagree Not Applicable I am better able to communicate with other members of a multidisciplinary team as a result of what I learned in this activity. Strongly Agree Agree Neutral Disagree Strongly Disagree Not Applicable I am better able to discuss how teamwork can contribute to continuous and reliable patient care. Strongly Agree Agree Neutral Disagree Strongly Disagree Not Applicable Please rate the projected impact of this activity on your knowledge, competence, performance, and patient outcomes: competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something).This activity increased my knowledge. Yes No No Change Please describe how your knowledge was increasedThis activity increased my competence. Yes No No Change Please describe how your competence was increasedThis activity will improve my performance. Yes No No Change Please describe how your performance will improveThis activity will improve my patient outcomes. Yes No No Change Please describe how your patient outcomes will improve Do you feel the activity was scientifically sound and free of commercial bias or influence? Yes No Please explainPlease identify how you will change your practice as a result of attending this activity (select all that apply).This activity validated my current practice; no changes will be madeCreate/revise protocols, policies, and/or proceduresChange the management and/or treatment of my patientsOtherHold CTRL key and click choice to select multiple responsesPlease specify your other changesPlease indicate any barriers you perceive in implementing these changes.CostLack of experienceLack of opportunity (patients, situation)Lack of resources (equipment)Lack of administrative supportLack of time to assess/counsel patientsReimbursement/insurance issuesPatient compliance issuesLack of consensus or professional guidelinesDo not work in a team environmentNo barriersOtherHold CTRL key and click choice to select multiple responsesPlease specify your other barriersWill you attempt to address these barriers in order to implement changes in your competence, performance, and/or patients’ outcomes? Not applicable No Yes Why not?How?For the content presented, how might the format of this activity be improved (select all that apply)?Format was appropriate; no changes neededInclude more case-based presentationsIncrease interactivity with attendeesAdd breakouts for SubtopicsAdd a hands-on instructional componentSchedule more time for Q and AOtherHold CTRL key and click choice to select multiple responsesDescribe other ways the this activity might be improved Overall, were the speakers knowledgeable regarding the content? Yes No Please explain how the speakers were not knowledgeable of the contentOverall, were the presentations balanced, objective, and scientifically rigorous? Yes No Please explain how the presentations were not balanced, objective, and/or scientifically rigorousDescribe any presentations that were exceptionalDescribe any presentations that did not meet your needs or expectationsFor future educational activities, please describe any clinical, educational, practice management, or other situations that you find difficult to manage or resolve that you would like to see addressed:
