Attachment L: Outcomes Survey_CME Activities

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Online CME Activity Outcomes Survey

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

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c).

Please list one change you made or tried to make:

(TEXT BOX)

Have you implemented the following?

	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						
Order fewer CBCs and blood cultures on 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
		         