kelliw@pain.comName___________________________________________________________________ Degree______________
Street_______________________________________________________________________________________
City_______________________________________________ State_____________ Zip Code _______________
Email _______________________________________________________________________________________
I certify that I completed this CME activity on (date): ________________________
The actual amount of time I spent in this activity was: _____ hours _____ minutes
Record your answers by filling in the blank with the correct letter from the corresponding question:
For list of questions, CLICK HERE.1.____ 2.____ 3.____ 4.____ 5.____
In order to measure the outcomes associated with this activity, the Dannemiller Memorial Educational Foundation would like to send you a survey regarding the material presented.
May we contact you (circle one)? YES NO
The Dannemiller Memorial Educational Foundation would appreciate your comments regarding the quality of the information presented. We thank you for your participation.
- The program objectives were fully met.
a. Strongly agree b. Agree c. Disagree d. Strongly disagree
- The quality of the educational process (method of presentation and information provided) was satisfactory and appropriate.
a. Strongly agree b. Agree c. Disagree d. Strongly disagree
- The educational activity has enhanced my professional effectiveness and improved my ability to:
- Treat/manage patients
a. Strongly agree b. Agree c. Disagree d. Strongly disagree
- Communicate with patients
a. Strongly agree b. Agree c. Disagree d. Strongly disagree
- Manage my medical practice
a. Strongly agree b. Agree c. Disagree d. Strongly disagree
- The information presented was without promotional or commercial bias.
a. Strongly agree b. Agree c. Disagree d. Strongly disagree
Comments: ____________________________________________
______________________________________________________
_____________________________________________________
- The program level was appropriate
a. Strongly agree b. Agree c. Disagree d. Strongly disagree
- Suggestions regarding this material or recommendations for future presentations:
______________________________________________________
______________________________________________________
_____________________________________________________
Mail or fax completed form to:
Dannemiller Memorial Educational Foundation
ATTN: Angiotensin II/00-185B
12500 Network Boulevard, Suite 101
San Antonio, TX 78249-3302
Fax: 210-697-9318Or submit via email to:
EXPIRATION DATE FOR CREDIT: DECEMBER 31, 2001