<p> [Name of activity] [date and location]</p><p>Phone xxx-xxx-xxxx <=these should be your contact numbers=> FAX xxx-xxx-xxxx</p><p>1. Please rate the following: 1=Strongly Disagree 2=Disagree 3=Neutral 4=Agree 5=Strongly Agree</p><p> 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: ______</p><p>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)</p><p>3. If Yes, please specify one change you will make in your practice:</p><p>4. Please circle your level of commitment in implementing this change: Lowest 1 2 3 4 5 Highest</p><p>5. Please circle your level of confidence in implementing this change: Lowest 1 2 3 4 5 Highest Now, go to question #8</p><p>6. If you answered No to question # 2, please explain why you will make no change following this session: </p><p>7. If you answered Uncertain to question # 2, please describe the reason for your uncertainty:</p><p>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: ______</p><p>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</p><p>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</p><p>Before training After training A. SAMPLE IN YELLOW FROM ANOTHER PROGRAM  Fill in with info for YOUR PROGRAM</p><p>B. Identify role of self-administration and drug onset cues in opioid efficacy</p><p>C. Identify strategies in place to combat the spread of chronic pain internationally and enhance collaborative efforts to improve pain treatment options</p><p>D. Know opioid pharmacotherapy choices for treatment, regulatory concerns with use of opioids and associated risks, benefits and alternatives</p><p>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</p><p>”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?</p><p>13. Please share suggestions to improve this learning activity:</p><p>Thank you!</p>