Institute for Continuing Medical Education

ACTIVITY EVALUATION/CREDIT REQUEST FORM Institute for Continuing Medical Education COURSE TITLE Course Day, Date & Time To receive AMA PRA Category 1 Credit™, please complete this evaluation form and mail or fax them to New York Eye and Ear Infirmary of Mount Sinai, Institute for Continuing Medical Education,310 East 14th Street – ICME, New York, NY 10003 (Fax: 212-353-5703). Your feedback helps us to determine the extent to which this educational activity has met its stated objectives, assess future educational needs, and create timely and pertinent future activities. Please provide all the requested information below. This ensures that your CME certificate is correct and is mailed to the proper address. It also enables us to contact you about future CME activities. Please print clearly or type. Illegible submissions cannot be processed.

PARTICIPANT INFORMATION

Last______First Name ______Specialty ______

Degree ___ MD ___ DO ___ PharmD ___ RPh ___ NP ___ RN ___ PA ___ Other ______Institution ______

Street Address ______City ______State ______ZIP Code ______Country ______

Phone ______Fax ______Email ______

I certify that I have participated in this activity and claim ______AMA PRA Category I Credits™. You may claim 1 AMA PRA Category I Credit TM for each hour you attended with a maximum of [insert # of credits]

Signature Required ______Date Completed ______OUTCOMES MEASUREMENT

Did you perceive any commercial bias in this educational activity? ___ Yes ___ No IMPORTANT: If you answered “Yes,” we urge you to be specific about where the bias occurred so we can address the perceived bias with the faculty member and/or in the subject matter in future CME activities. ______Circle the number which best reflects the degree to which the following Learning Objectives were met: 5 = Strongly Agree 4 = Agree 3 = Neutral 2 = Disagree 1 = Strongly Disagree After completing this activity, I have improved my ability to: Insert Learning Objective #1 5 4 3 2 1 Insert Learning Objective #2 5 4 3 2 1 Insert Learning Objective #3 5 4 3 2 1 Insert Learning Objective #4 (add or delete lines as needed) 5 4 3 2 1

Please rate the content and presentation skills of the speaker(s): 5 = Excellent 4 = Good 3 = Average 2 = Fair 1 = Poor Insert lecture topic Content 5 4 3 2 1 Insert speaker’s name Presentation 5 4 3 2 1 Insert lecture topic Content 5 4 3 2 1 Insert speaker’s name Presentation 5 4 3 2 1 Insert lecture topic Content 5 4 3 2 1 Insert speaker’s name Presentation 5 4 3 2 1 Insert lecture topic Content 5 4 3 2 1 Insert speaker’s name Presentation 5 4 3 2 1 ROUNDTABLE & VIDEO PRESENTATIONS: Content 5 4 3 2 1 Zonular Deficiencies/Microendoscopy Cases and Discussion Ike Ahmed, MD; Boris Malyugin, MD; Kenneth J. Rosenthal, MD; Steven Safran, MD Presentation 5 4 3 2 1 Treatment of Patients with Iris Defects Content 5 4 3 2 1 Kenneth J. Rosenthal, MD Presentation 5 4 3 2 1 ROUNDTABLE & VIDEO PRESENTATIONS: Iris Defect Problems Content 5 4 3 2 1 Ike Ahmed, MD; Boris Malyugin, MD; Kenneth J. Rosenthal, MD; Steven Safran, MD Presentation 5 4 3 2 1 Cataract Surgery with Corneal Disease: DSAEK Strategies Content 5 4 3 2 1 David Ritterband, MD Presentation 5 4 3 2 1 ROUNDTABLE & VIDEO PRESENTATIONS: Corneal and Lens Problems Content 5 4 3 2 1 David Ritterband, MD & Steven Safran, MD Presentation 5 4 3 2 1

Please COMPLETE BOTH SIDES of this form. Y:\CME FORMS AND INSTRUCTIONS 2014\CME_7_EVALUATION-CREDIT REQUEST FORM TEMPLATE updated 3-11-14 ACTIVITY EVALUATION/CREDIT REQUEST FORM page 2 Institute for Continuing Medical Education Please rate the content and presentation skills of the speaker(s): 5 = Excellent 4 = Good 3 = Average 2 = Fair 1 = Poor Presentation 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1 Content 5 4 3 2 1 Presentation 5 4 3 2 1

1. Please list one or more things, if any, you learned from participating in this educational activity that you did not previously know:

______

2. As a result of the knowledge gained in this activity, how likely are you to implement changes in your practice?

Please circle the number that best reflects your intent to change. 4 3 2 1 1 4 = Definitely will implement changes; 3 = Likely will implement changes; 2 = Likely will not make changes; 1 = Definitely will not make any changes

Please describe the change(s) you plan to make: ______

______

3. Related to what you learned in this activity, what barriers to implementing these changes or achieving better patient outcomes do you face?

______

4. Please check the Core Competencies (as defined by the ACGME) that were enhanced for you through your participation in this activity. ____Patient Care ____Interpersonal and Communication Skills ____Professionalism

____Medical Knowledge ____Practice-Based Learning and Improvement ____Systems-Based Practice

5. What other topics would you like to see covered in future activities? ______

______

Additional Comments: ______

______

Please COMPLETE BOTH SIDES of this form. Y:\CME FORMS AND INSTRUCTIONS 2014\CME_7_EVALUATION-CREDIT REQUEST FORM TEMPLATE updated 3-11-14 ACTIVITY EVALUATION/CREDIT REQUEST FORM Institute for Continuing Medical Education

THANK YOU!

Please COMPLETE BOTH SIDES of this form. Y:\CME FORMS AND INSTRUCTIONS 2014\CME_7_EVALUATION-CREDIT REQUEST FORM TEMPLATE updated 3-11-14