204 PREANESTHETIC ASSESSMENT by sSO47VQ4

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									{Enter Activity Title here}

                                                                                                                               11. What topics would you like to see included
To receive CME credit, you must complete this form                3. The content was not affected by any faculty conflict of      in future programs ?
including the time attestation, and evaluation, and return        interest.                                                    _____________________________________
the form with a check for {enter amount, if any required                                                                       _____________________________________
                                                                  Strongly Agree    Agree      Disagree Strongly Disagree
for CME credit} made payable to NYMC-CME prior to
{enter lesson expiration date here} to New York Medical                                                                        12. Were you able to contact the CME office at
                                                                  4. This activity improved my skills.                             (914) 594-4487 if you required administrative
College, Office of CME, Vosburgh Pavilion, Room 230,
Valhalla, New York 10595. No credit will be awarded               Strongly Agree    Agree      Disagree Strongly Disagree         assistance or to contact the author John Q. Elf
for lessons that have no completed and signed                                                                                      (johnqelf@santasworkshop.org) for a question
attestation or are received after the expiration date.            5. I am satisfied with the content of this activity.             about content?
                                                                  Strongly Agree    Agree      Disagree Strongly Disagree
                                                                                                                                 PLEASE TYPE OR PRINT CLEARLY
New York Medical College designates this educational              6. The information I gained from this activity will be
activity for a maximum of {enter # of credits here} AMA              applicable to my practice.                                Name ____________________________________
PRA Category 1 Credit(s)™. Physicians should only
claim credit commensurate with the extent of their                Strongly Agree    Agree      Disagree Strongly Disagree
participation in the activity.                                                                                                 Degree ___________________________________
                                                                  7. The information I gained from this activity will
I certify that I completed this CME activity; the actual             assist me in improving the health of my patients.         Address __________________________________
time I spent on this activity was:                                Strongly Agree    Agree      Disagree Strongly Disagree
                                                                                                                               City _______________ State _______ Zip ______
____ hours _____ minutes.                                         Strongly Agree    Agree      Disagree Strongly Disagree
                                                                                                                               Email _____________________________________
                                                                  8. The format used for this activity was appropriate.
Signature ______________________________                                                                                       Comments: ________________________________
                                                                  Strongly Agree    Agree      Disagree Strongly Disagree

Course Evaluation                                                 9. Which parts of the activity were most useful?             __________________________________________
                                                                  ______________________________________
Your frank evaluation of this activity will be helpful in         ______________________________________                       __________________________________________
improving our CME programs. Your assistance is                    ______________________________________
greatly appreciated.
                                                                                                                               __________________________________________
1. This activity met the stated objectives.                       10. Were any parts of the activity unsatisfactory
                                                                      or inappropriate? If so, which?
Strongly Agree     Agree      Disagree Strongly Disagree          _______________________________________
                                                                  _______________________________________
2. This activity was free from promotional and
   commercial bias.
                                                                  ____________________________________

Strongly Agree     Agree      Disagree Strongly Disagree




C:\Docstoc\Working\pdf\002653ba-4bcc-4a9c-9289-8cd60a75dbed.doc                                                                             revised:02/08/06

								
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