You Are the Key: Getting into the Routine of Recommending Cancer Prevention
1.
Name:
 

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2.
Occupation:
MD
PA
APRN
RN
LPN
Other  
3.
Are you requesting CME or CEU's?
Yes
No
4.

If requesting CME/CEU, please indicate payment method:. 

Credit Card/Paypal (Single Registration)
Check (Single Registration)
Credit Card/Paypal (Full Series Registration)
Check (Full Series Registration)
5.

Practice/Organization:

 

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6.

Mailing Address: 

 

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7.
CONTENT
 Strongly Agree Agree Disagree Strongly Disagree  
Was organized and easy to follow  
Met the objective(s)  
8.
TRAINER
 Strongly Agree Agree Disagree Strongly Disagree  
Knows and understands the topic  
Was well organized and prepared  
Was clear and easy to follow  
9.
RELEVANCE - as a result of this training...
 Strongly Agree Agree Disagree Strongly Disagree  
I gained factual information  
I gained a better understanding of topic  
I have developed more skills and competencies  
10.
Suggestions for improvements:
 

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11.
Suggestions for Future Topics:
 

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12.
Required for Physicians, PA's, APRN's, Requesting CME's
This was a quality CME activity and met the following objectives:
 Strongly Agree Agree Disagree Strongly Disagree  
Define the importance of HPV vaccination for cancer prevention and the rationale for vaccinating at age 11 or 12  
Describe the current status of uptake and impact in Connecticut  
Understand the significance of the clinician recommendation for HPV vaccination  
Employ strategies for making effective recommendations to families of 11-12 year olds  
  • Comment:

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13.
Required for Physicians, PA's, APRN's, Requesting CME's
Please Rate the Following Statements
 Strongly Agree Agree Disagree Strongly Disagree  
This CME activity will favorably influence my ability to practice medicine as a leader, teacher and researcher  
The program clearly indicated whether or not this CME activity received commercial support  
I observed no overall commercial bias in this educational session  
I would definitely recommend this CME activity to my colleagues  
  • Comment:

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14.
Did the CME program communicate any conflict of interest or lack thereof?
Yes (if 'yes" please answer next question)
No
I do not recall
15.

If you answered YES to the above question, how was the conflict of interest communicated?

Promotional material
PPT slides
Introductory Remarks
Handouts
I do not recall
Other