BMW One-Day Workshops – CME Evaluation CME Evaluation Form - BMW One-Day Workshops - 2016 - Non-Social Work Please complete the form below to claim your CME. Name * First and Last Name (This is the name that will appear on your CME Certificate) 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 OtherOther How can the Ohio AAP Assist in meeting your education needs? * Please select the BMW One-Day Workshop that you attended: February 19, 2016 March 4, 2016 May 17, 2016 June 7, 2016 August 19, 2016 At the conclusion of this activity, are you able to: Demonstrate confidence and competence in communication skills that support a therapeutic alliance with children and families affected by mental health issues? * Yes No Implement evidence-based strategies for assessment and treatment of common mental health conditions, including anxiety, depression, inattention and impulsivity? * Yes No Implement screening tools for assessment and treatment of common mental health conditions, including postpartum depression screening, family environment screening, adolescent depression screening, and substance use screening? * Yes No Utilize quality improvement resources to develop an aim statement and define an initial PDSA cycle focused on implementation of behavioral/mental health screening tools? * 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 Please enter the amount of credit that you are claiming for this activity - maximum of 6.5 hours. * .5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 You may only claim credit that is commensurate with your participation in the activity. Are you a physician that is planning to participate in the BMW Online MOC Part IV? Yes No We will follow-up with all interested individuals with information about registering for a Technical Assistance Webinar. 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.