Evaluation Form

The planning committee would like your opinion and comments on this educational activity. This will assist in planning future educational activities. Please leave the completed evaluation form with program personnel at the end of the activity.

QUALITY OF INSTRUCTION: (if multiple presenters, evaluate the following for each speaker/presenter individually)

Vickie Carlyle RN, BSN-CCRN	Excellent	Good	Fair	Poor
Knowledge of subject
Organization and clarity of content
Effectiveness of teaching methods
Joe Basha CCP, LP	Excellent	Good	Fair	Poor
Knowledge of subject
Organization and clarity of content
Effectiveness of teaching methods
Daniel Rhodes Kievlan MD	Excellent	Good	Fair	Poor
Knowledge of subject
Organization and clarity of content
Effectiveness of teaching methods
Yeunju, (Michelle) Lee, Pharm.D, BCCCP	Excellent	Good	Fair	Poor
Knowledge of subject
Organization and clarity of content
Effectiveness of teaching methods
Mike Brown BSN, CCP, LP	Excellent	Good	Fair	Poor
Knowledge of subject
Organization and clarity of content
Effectiveness of teaching methods
Heather Robinson, NP	Excellent	Good	Fair	Poor
Knowledge of subject
Organization and clarity of content
Effectiveness of teaching methods
Vivekkumar B. Patel, M.D. cardiothoracic surgeon	Excellent	Good	Fair	Poor
Knowledge of subject
Organization and clarity of content
Effectiveness of teaching methods

LEARNING OUTCOMES: (if multiple outcomes, evaluate the following for each outcome individually)

As a result of this activity, I will be able to take the ELSO Adult ECMO certification exam once clinical bedside hours are met:

Yes

If no, please explain:

Were the presentation(s) free from commercial bias?

Yes

If no, please explain:

As a result of this activity, please share at least one action you will take to change your professional practice/ performance:

ADMINISTRATIVE ARRANGEMENTS:

	Satisfactory	Unsatisfactory
Promotional information provided adequate information
Registration process was efficient
Scheduling of the activity met my needs

General comments about the program:

Suggestions for future program topics:

Please indicate how well each statement met your expectations

	Strongly Agree	Agree	Not Applicable	Disagree	Strongly Disagree
Addressed competencies identified by my specialty
Provided clear evidence to support content
Overall the content of this activity was valuable to me
The educational objectives for this activity were met
This activity increased my competence
This activity will improve my performance
This activity will improve my patient outcomes

I plan to make the following changes in my practice:

Create/revise protocols, policies, and/or procedures
Change the management and/or treatment of my patients
None. The activity validated my current practice
Other: Please explain

Identify barriers you perceive in implementing these changes:

Cost
Knowledge
Lack of time to assess/counsel patients
Lack of administrative support/resources
Reimbursement/insurance issues
Patient compliance issues
Lack of consensus or professional guidelines
Other:

Were disclosures of relevant financial relationships of the presenter/s made prior to the education presented?

Yes

Was this activity free from commercial bias?

Yes

If no, explain