CME participation and evaluation form

* Last name

* First name

Middle initial

Degree

* Title
--Select one-- Physician Resident Medical student Physician assistant Nurse Administrator Other health care professional

* Please select one:
 Physician: Certificate of credit
 Non-physician: Certificate of participation

* If you are a physician, please complete the following:   

Medical Education Number

This 11 digit number is assigned to all physicians in the US for identification and recording of basic information. If you are an AMA member, this number is on your membership card. If you do not have your ME number, you can obtain it by calling the AMA at 1-800-262-3211 or learn how to locate your medical education number.

* E-mail address

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* Telephone number

* City

* State
Choose a state Alaska Alabama Arkansas Arizona 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 Virginia Washington West Virginia Wisconsin Wyoming

* Hours of participation to claim
 .25          .50          .75          1.00

Overall evaluation

1. Overall, I would rate this activity positively

2. The activity effectively targeted my needs

3. The activity was appropriate for my knowledge/skill level

4. The format of the activity was effective

5. The activity was well organized

6. The activity met my expectations

7. Learning this content will positively impact how I deliver care to my patients

8. I would recommend this activity to a colleague

9. The program met the educational objectives for the following:

a. recognize health care disaprities in the United States among racial-ethnic minorities

b. apply strategies to reduce health care disparities in practice

c. describe the impact of communication barriers on patient care

d. explain strategies to enhance patient-provider communication among racial-ethnic minorities

10. Will you change how you practice as a result of this activity?

 Yes
 No

If yes, how?

11. Did you perceive commercial bias during this activity?

 Yes
 No

If yes, please specify:

12. How could this activity be improved?

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