MOC Part II – CME Evaluation – PMP Regional Trainings CME Evaluation - PMP Regional Trainings Please complete the form below to claim your CME. Name * Credentials Email Address * Name of Practice * Practice - Street Address * Practice - City * Practice - State * Ohio Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Practice - County * Number of Physicians at Your Practice * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 20-24 24-29 30+ Number of Physicians Planning to Use PMP * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 20-24 24-29 30+ Percentage (%) of Population that is on Medicaid: * Average # of Patients Seen Per Week (Unduplicated): * Specialty * Primary Care Medical Subspecialty Surgeon Hospitalist Urgent Care Other How can the Ohio AAP Assist in meeting your education needs? * At the conclusion of this activity, are you able to: Define the provider’s role in obesity prevention based on the Expert Committee Recommendations endorsed by the American Academy of Pediatrics? * Yes No Identify the reason for and importance of screening for, assessing, and managing excessive weight trajectories starting from birth? * Yes No Identify the Parenting at Mealtime and Playtime (PMP) strategies that will enhance your pediatric obesity prevention efforts? * Yes No Describe the concepts that make PMP an effective way to build sound nutrition and activity foundations through developmentally appropriate parenting techniques? * Yes No As a result of participating in this learning activity, do you intend to make changes in your practice? * Yes No If yes to the previous question: Please describe what you will do differently in practice [performance]. How will you accomplish this change in practice [competence]? If no to the previous question: Please describe why you are not planning to do anything differently in practice [performance]. I plan to use the following resource(s) that were provided today: (Check all that apply) Parenting at Mealtime and Playtime Handouts Pound of Cure Handouts Ounce of Prevention Handouts Pocket Guides PMP Mobile App N/A - I don't plan to use any of the resources. After participating in this activity, would you be interested in joining the full MOC Part IV Learning Collaborative in Fall 2016? * Yes No, because: On a scale of 1-5, with 1 being not at all prevalent and and 5 being extremely prevalent, how prevalent do you feel obesity is in your practice? * 1 2 3 4 5 On a scale of 1-5, with 1 being Strongly Disagree and 5 being Strongly Agree, please rate the following statement: The speaker was knowledgeable and able to effectively teach the content. * 1 2 3 4 5 How would you rate your overall satisfaction with this activity? * Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied Additional Feedback/Comments Feedback on module content, suggestions for future revisions, etc.