[Name of activity] [date and location]

Phone xxx-xxx-xxxx <=these should be your contact numbers=> FAX xxx-xxx-xxxx

1. Please rate the following: 1=Strongly Disagree 2=Disagree 3=Neutral 4=Agree 5=Strongly Agree

a. The material was organized clearly to facilitate learning 1 2 3 4 5 b. Content will enhance my practice 1 2 3 4 5 c. Information provided will improve my patient outcomes 1 2 3 4 5 d. Content was free of commercial bias or influence Yes No e. This presentation format facilitated my learning 1 2 3 4 5 f. Overall, this learning activity met the educational objectives 1 2 3 4 5 If you indicated in 1d above that there was commercial influence, please describe: ______

2. As a result of participating in this session, will you make changes in your practice? (Circle one) Yes (go to question #3) No (go to question #6) Uncertain (go to question #7)

3. If Yes, please specify one change you will make in your practice:

4. Please circle your level of commitment in implementing this change: Lowest 1 2 3 4 5 Highest

5. Please circle your level of confidence in implementing this change: Lowest 1 2 3 4 5 Highest Now, go to question #8

6. If you answered No to question # 2, please explain why you will make no change following this session:

7. If you answered Uncertain to question # 2, please describe the reason for your uncertainty:

8. Please describe how this educational program might improve your patient outcomes: 2 9. Demographics: a. Gender: □ M □ F b. Age: □ 20 – 29 □ 30 – 39 □ 40 – 49 □ 50 – 59 □ 60 or older c. Number of years in practice: ______d. Degree(s) and certification(s): ______e. Clinical specialty: ______

For your reference, the following were the educational objectives for this activity: 1. Please restate the educational objectives of your activity here, and 2. these should be reflected, in abbreviated form in the section below in Question #10 3. this listing serves to remind the learners of the objectives in total, and allows you to abbreviate them in Question #10 below for the sake of brevity Confidence Rating

10. With 1 being very low and 5 being very high, for each item below, please rate your confidence before and after this training from 1 to 5: 1 2 3 4 5 Very Low Low Neutral High Very High Confidence Confidence Confidence Confidence

Before training After training A. SAMPLE IN YELLOW FROM ANOTHER PROGRAM  Fill in with info for YOUR PROGRAM

B. Identify role of self-administration and drug onset cues in opioid efficacy

C. Identify strategies in place to combat the spread of chronic pain internationally and enhance collaborative efforts to improve pain treatment options

D. Know opioid pharmacotherapy choices for treatment, regulatory concerns with use of opioids and associated risks, benefits and alternatives

11. Please rate the following concurrent sessions: (5=Highest) insert a section for each speaker Date Session I: Topic Day, time Presenter: Title Objective: Describe …[optional] Usefulness of content 1 2 3 4 5 Presentation skills 1 2 3 4 5 Objective achieved 1 2 3 4 5 Presenter: Title Objective: Describe …[optional]… Usefulness of content 1 2 3 4 5 Presentation skills 1 2 3 4 5 Objective achieved 1 2 3 4 5

”Block and copy and paste” as many of these blocks above as you have presentations. 3 12. Why did you choose to participate in this learning activity?

13. Please share suggestions to improve this learning activity:

Thank you!