Southern Regional AHEC
Provider Directed Activity Form
Event Title: _12th Annual SESS_____________________________________
Session Title:_______________________________ _____
Date(s) of Activity: _____April 15-17, 2011___ ____________
Faculty Name and Credentials: _______________________________________
Purpose/Goal/Description of content to be covered:
Teaching Methodolog(ies) (check all that apply):
Lecture Discussion Images (i.e. ppt, video)
Demonstration Return Demonstration Case Studies
Examples Application to Practice Role Play
Small Group Work Handouts Other ________________
Delivery Method (check all that apply)
Live Recorded (audio/video) Internet/computer based
Total teaching time in minutes: 60 minutes
Objectives: (ideally one objective per teaching hour)
Upon completion of this educational activity, the participant will be able to:
1.
Content Information/Outline
Time Frame Topic
Learner Feedback Mechanism(s):
Q & A during activity Testing results Post-course follow-up
Teaching activities Other________________________________
Methods of Evaluation:
Pre- and/or Post-test Return Demonstration Learner Input
Faculty Input Planning Committee Input Direct Observation
Other:__________________
Evaluation Level/Category:
SR AHEC uses Alspach’s Evaluation Model:
Level 1: Learner Satisfaction
Level 2: Measure of Learning,
Level 3: Application to practice
Level 4: Impact on practice
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