Dear Colleague:

Please evaluate this program in order to help us plan future programs. Once finished completing survey hit the submit button.

Thank you.

Speaker :
Topic :

DISCLOSURE STATEMENT:
Speaker plans to present an unapproved/investigative use of a commercial product or device
Yes	No
Speaker has disclosed a significant financial relationship
Yes	No

PLEASE RATE THIS PRESENTER: Delivery & Quality of Presentation: VERY GOOD SATISFACTORY NOT SATISFACTORY

Practice Oriented and of Value to You in Practice: VERY SOME-WHAT NOT AT ALL Was adequate time provided to cover the material? Yes No

Please rate the quality of any audiovisuals used:
VERY GOOD	SATISFACTORY	NOT SATISFACTORY
Please rate the effectiveness of the learning materials provided (if applicable)
VERY GOOD	SATISFACTORY	NOT SATISFACTORY
Please rate the room/facility for the program:
VERY GOOD	SATISFACTORY	NOT SATISFACTORY

Will you change any aspects of your practice related to today’s presentation?
Yes	No
If yes, what aspect?

Did you perceive any undue commercial bias in this presentation?
Yes	No
If yes, what aspect?

List any topics you would like presented in the future:

Please list three things you learned from this presentation. (one item in each of the following boxes and all three boxes must be filled out to complete this form)

Other comments:

Thank you for your help in evaluating this program.

This program was approved for 1.00 Category 1 CME credit hours toward the AMA Physicians Recognition Award. By placing my signature below, I am attesting to my attendance at this conference. SIGNATURE REQUIRED FOR CME CREDIT

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