Form #7 Sample CME Followup Questionnaire

BCM Online Activity Follow-up Outcomes Assessment

Activity (#):
Date:
Director:

According to our records you attended this course. We would appreciate your taking a moment now to anonymously answer a few follow-up questions.

Your professional category/degree:

 MD/DO—in practice  Nurse Specialist (e.g., CRNA, NP)  PA-C

 MD/DO—Resident/Fellow  Nurse (e.g., RN, LVN)  Allied Health Professional

 Pharmacist  PhD/PsyD/EdD/DrPH  Other

Have the knowledge and skills acquired as a result of the program helped enhance your quality of patient care? (Select one answer.)

Yes,...  helped considerably

 helped somewhat

 helped slightly

• No

• Not applicable

Did you try to make any change as a result of things learned during the program?

(Select one answer.)

Yes,...  working well

 with some success

 but with no success

No,...  but still plan to

 but validated current practice

 due to prohibitive barriers

 not needed

• Not applicable

Please list one change you made or tried to make:

(TEXT BOX)

Have you implemented the following? (Please rate each.)

	Yes	Tried; but no success	Still plan to	Was practicing before activity	No	Not applicable
Order upper GI and abdominal decompression for conditions such as malrotation of the intestine or intestinal atresias						
Based on new data on bacteremia after implementation of the pneumococcal vaccine, order fewer CBCs and blood cultures on previously identified high risk children than were ordered before attending this activity						

What barriers to change have you faced? (Leave blank if not applicable.)

	None / Minimal	Sizeable	Insurmountable
Insurance reimbursement			
Formulary			
Cost effectiveness			
Time management			
Administrative/Support staff			
Patient compliance			

Please rate your knowledge or confidence level for each of the following:

	­
	Knowledge of emerging drugs of use such as “fry,” salvia, divinorum, and anabolic steroids
		No Some High Very High Knowledge Knowledge Knowledge Knowledge 1 2 3 4 5 6 7 8 9 10
		         
	Confidence in recognizing children and adolescents with a drug overdose and administering appropriate treatment
		No Some High Very High Confidence Confidence Confidence Confidence 1 2 3 4 5 6 7 8 9 10
		         
	Confidence in identifying conditions in children with abdominal pain that require surgical intervention
		No Some High Very High Confidence Confidence Confidence Confidence 1 2 3 4 5 6 7 8 9 10
		         
	Confidence in managing genitourinary emergencies in children such as acute testicular disorders in males
		No Some High Very High Confidence Confidence Confidence Confidence 1 2 3 4 5 6 7 8 9 10
		         

Any other comments:

(TEXT BOX)

Please provide the following information to aid us in anonymously linking responses to the earlier assessment:

a. 4-digit day/month of birth (e.g., Jan. 15 = 01/15): _{  /  }

b. 2-digit year of graduation from medical school (e.g., 1973 = 73): _{ }

c. First 3 letters of city in which you attended medical school (e.g., El Paso = ELP): _{  }

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