1 Start 2 - 3 Complete

Did this activity: *

	Not at All	Insufficiently	Neutral	Sufficiently	Completely
Meet the stated learning objectives?	Meet the stated learning objectives? - Not at All	Meet the stated learning objectives? - Insufficiently	Meet the stated learning objectives? - Neutral	Meet the stated learning objectives? - Sufficiently	Meet the stated learning objectives? - Completely
Address the competencies or attributes relevant to your role?	Address the competencies or attributes relevant to your role? - Not at All	Address the competencies or attributes relevant to your role? - Insufficiently	Address the competencies or attributes relevant to your role? - Neutral	Address the competencies or attributes relevant to your role? - Sufficiently	Address the competencies or attributes relevant to your role? - Completely
Equip you with new information to overcome barriers to performance?	Equip you with new information to overcome barriers to performance? - Not at All	Equip you with new information to overcome barriers to performance? - Insufficiently	Equip you with new information to overcome barriers to performance? - Neutral	Equip you with new information to overcome barriers to performance? - Sufficiently	Equip you with new information to overcome barriers to performance? - Completely
Offer knowledge or skills to collaborate with your team?	Offer knowledge or skills to collaborate with your team? - Not at All	Offer knowledge or skills to collaborate with your team? - Insufficiently	Offer knowledge or skills to collaborate with your team? - Neutral	Offer knowledge or skills to collaborate with your team? - Sufficiently	Offer knowledge or skills to collaborate with your team? - Completely

I expect that my participation in this activity will improve my: *

	Not at All	Insufficiently	Neutral	Sufficiently	Completely
Knowledge (the new information gained)	Knowledge (the new information gained) - Not at All	Knowledge (the new information gained) - Insufficiently	Knowledge (the new information gained) - Neutral	Knowledge (the new information gained) - Sufficiently	Knowledge (the new information gained) - Completely
Competence (skills, abilities, and strategies gained from the new information)	Competence (skills, abilities, and strategies gained from the new information) - Not at All	Competence (skills, abilities, and strategies gained from the new information) - Insufficiently	Competence (skills, abilities, and strategies gained from the new information) - Neutral	Competence (skills, abilities, and strategies gained from the new information) - Sufficiently	Competence (skills, abilities, and strategies gained from the new information) - Completely
Performance (implementing the new skills, abilities, and strategies)	Performance (implementing the new skills, abilities, and strategies) - Not at All	Performance (implementing the new skills, abilities, and strategies) - Insufficiently	Performance (implementing the new skills, abilities, and strategies) - Neutral	Performance (implementing the new skills, abilities, and strategies) - Sufficiently	Performance (implementing the new skills, abilities, and strategies) - Completely
Patient Outcomes (the potential effect from gained skills, abilities, and strategies)	Patient Outcomes (the potential effect from gained skills, abilities, and strategies) - Not at All	Patient Outcomes (the potential effect from gained skills, abilities, and strategies) - Insufficiently	Patient Outcomes (the potential effect from gained skills, abilities, and strategies) - Neutral	Patient Outcomes (the potential effect from gained skills, abilities, and strategies) - Sufficiently	Patient Outcomes (the potential effect from gained skills, abilities, and strategies) - Completely

Please rate the following: *

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I would recommend this activity to others.	I would recommend this activity to others. - Strongly Disagree	I would recommend this activity to others. - Disagree	I would recommend this activity to others. - Neutral	I would recommend this activity to others. - Agree	I would recommend this activity to others. - Strongly Agree
The instructional effectiveness and expertise of the faculty were excellent.	The instructional effectiveness and expertise of the faculty were excellent. - Strongly Disagree	The instructional effectiveness and expertise of the faculty were excellent. - Disagree	The instructional effectiveness and expertise of the faculty were excellent. - Neutral	The instructional effectiveness and expertise of the faculty were excellent. - Agree	The instructional effectiveness and expertise of the faculty were excellent. - Strongly Agree
The learning format was appropriate for this activity.	The learning format was appropriate for this activity. - Strongly Disagree	The learning format was appropriate for this activity. - Disagree	The learning format was appropriate for this activity. - Neutral	The learning format was appropriate for this activity. - Agree	The learning format was appropriate for this activity. - Strongly Agree

Based upon your participation in this activity, do you intend to change your performance? *

Yes, I plan to implement changes in my practice based on the information presented.

No, my current practice is consistent with the information presented.

Please specify the type of change you plan to implement. (Select all that apply.) *

Patient Care (e.g., apply compassionate, appropriate, and effective treatment to patients)

Practice-based learning and improvement (e.g., assimilate new practices and/or guidelines into performance)

Interpersonal and communication skills (e.g., communicate effectively with patients, families, and colleagues)

Professionalism (e.g., employing ethical principles and a commitment to professional responsibilities)

Systems-based practice (e.g., call on system resources to perform optimally)

Work in interdisciplinary teams (e.g., collaborate in teams to ensure performance is continuous and reliable)

Employ evidence-based practice (e.g., integrate the best research for optimum performance)

Apply quality improvement (e.g., identify errors and hazards in care)

Utilize informatics (e.g., employ information technology to support decision-making)

Other (Please Specify.)

Please specify the type of change you plan to implement. (Select all that apply.) Other (Please Specify.)

Are there any barriers or problems that might prevent you from implementing changes in your performance? (Select all that apply.) *

No Barriers

Lack of evidence-based guidelines

Lack of practice and patient based guidelines

Organizational or institutional barriers

Limited time

Insurance or financial

Increased workload

Lack of patient adherence or compliance

Other (please indicate below)

Are there any barriers or problems that might prevent you from implementing changes in your performance? (Select all that apply.) Other (please indicate below)

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