MOBI 2015 Trainer Feedback Program * MOBI TIES Trainer Name * Trainer Email * Site Name * Presentation Date * Presentation completed including PDSA * Yes No Why not completed? Total number of attendees * Physicians Adv Practice Nurse/PA Nurses Medical Assistants Other List questions asked by audience and indicate any needed follow-up Any slides, material or information to be added or deleted? * Yes No Slides, material or information to be added or deleted AFIX performed prior to MOBI or TIES program? * Yes No Date AFIX performed AFIX Planned at a Later Date? Yes No Maybe AFIX planned date Reason for no planned AFIX Does the practice expect you to follow up in one month * Yes No Additional Comments If you are human, leave this field blank.