CNE Evaluation Form – MOBI & TIES Train-the-Trainer October 2018 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 * Experience Level * New Trainer Experienced Trainer Training Objectives: At the conclusion of this activity, are you able to: Define the MOBI background and mission * Yes No Identify current recommended childhood and adolescent immunizations schedules * Yes No Describe recent changes in immunizations recommendations * Yes No Describe the Plan-Do-Study-Act (PDSA) Cycle Yes No Identify procedures for conducting MOBI & TIES programs Yes No Identify online documentation for MOBI & TIES programs Yes No Speaker for New Trainers Only: On a scale of 1-5, with 1 being Strongly Disagree and 5 being Strongly Agree, please rate the following statements. Speaker demonstrated teaching effectiveness: Rebecca Brady, MD, FAAP * 1 2 3 4 5 Speaker demonstrated teaching effectiveness: Robert Frenck, Jr., MD, FAAP * 1 2 3 4 5 Speakers: On a scale of 1-5, with 1 being Strongly Disagree and 5 being Strongly Agree, please rate the following statements. Speaker demonstrated teaching effectiveness: Beth Barker * 1 2 3 4 5 Speaker demonstrated teaching effectiveness: Dave Feltz * 1 2 3 4 5 Speaker demonstrated teaching effectiveness: Samantha Anzeljc, PhD * 1 2 3 4 5 OVERALL PRESENTATION: On a scale of 1-5, with 1 being Strongly Disagree and 5 being Strongly Agree, please rate the following statements. The presentation was well organized and logically sequenced. * 1 2 3 4 5 The material was not too difficult to understand. * 1 2 3 4 5 I gained new information. * 1 2 3 4 5 How would you rate your overall satisfaction with this activity? * Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied Additional Comments: By signing or typing your name, you confirm your identity and attest to attending the entire educational activity. * Clear If you are human, leave this field blank.
