CME Evaluation Form – PVS 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: Increase quality and administration of preventative services for eye health in pediatric health care practices to prevent vision loss in children ages 3 to 5? * Yes No Properly explain test results (normal or abnormal) to families and determine the necessary next steps for comprehensive care, including resources and referrals? * Yes No Display competency in the proper use of preschool vision screening equipment within a primary care setting? * 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 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.