TIES Evaluation 9/1/16 – 9/1/17 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 Date of Presentation * This is the date that will be populated on your certificate. Did you attend the entire 60 minute presentation? * Yes No You may not claim CME unless you attended the entire presentation. Please rate whether the following objectives of the program were met: Describe diseases prevented through adolescent immunization * Yes No Review immunization schedules for adolescents * Yes No Review issues related to vaccinating adolescents, such as strategies and safety * Yes No Discuss TIES Best Practices * Yes No Introduce Plan-Do-Study-Act (PDSA) Worksheet * 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]. Implement or update a reminder or recall system. Make changes in office flow or another office system. Provide education and/or resources for staff. Provide education and/or resources for parents/patients. OtherOther 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.