CME Evaluation Form – PMP Learning Session – December 2015 Name * First Last Name * Last Credentials * Practice/Organization * Email Address * Phone Number * Address * Address 2 City * State * ------ 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 Zip * Specialty * Primary Care Medical Subspecialty Surgeon Hospitalist Urgent Care How can the Ohio AAP Assist in meeting your education needs? * At the conclusion of this activity, are you able to: Define best strategies in building a healthy nutrition foundation within the first 5 years of life? * Yes No Explain the purpose of the PMP curriculum as it relates to well child visits for children birth to 5 years of age? * Yes No Review immunization against influenza and discuss new strategies toward a universal flu vaccine? * Yes No Determine proper situations to use parenting-centered nutrition and activity anticipatory guidance, as well as show competency in the use of PMP materials? * Yes No Identify early risk factors for obesity? * Yes No Explain the importance of evaluating a child’s growth trajectory, family history, and behaviors in identifying a child's risk for excess weight? * Yes No Outline the benefits of Quality Improvement through the use of the Key Driver Diagram, Model for Improvement, and Plan-Do-Study-Act cycles? * Yes No On a scale of 1-5, with 1 being Strongly Disagree and 5 being Strongly Agree, please rate the following statements. The content matched my current or potential scope of practice. * 1 2 3 4 5 The speaker was knowledgeable and able to effectively teach the content. * 1 2 3 4 5 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]? How would you rate your overall satisfaction with this activity? * Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied The Ohio AAP has been authorized to visit your practice and assist with data collection - would you like to have an Ohio AAP staff member assist with your data collection? * Yes No After attending the Learning Session, do you know anyone else that could benefit from joining this collaborative? If so, the PMP Project Team is giving you the opportunity to earn a $25 Gift Card for referring at least 2 providers/practices to participate in the current wave of the Parenting at Mealtime and Playtime Learning Collaborative! If you would like to take advantage of this opportunity, please provide a name, email and phone number for each referral in the box below. As an additional reward, you will receive $100 for each referral that chooses to participate in the project! If you need time to reflect or find contact information, please send your referrals to Lisa Weston at email@example.com. By signing or typing your name, you confirm your identity and agree to the conditions and disclosures of this survey. * Clear If you are human, leave this field blank.