Form 5 Module Evaluation

OMB # 0925-XXXX

Expiration Date: XX/XXXX

MODULE [COURSE] EVALUATION

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

Were the following activity objectives met?

After participating in this activity, the participant will demonstrate the ability to:	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
1a. Identify sex and gender differences in the presentation, risk factors, and pathophysiology of disease.	O	O	O	O	O
1b. Describe how sex and gender differences in risk factors and pathophysiology affect patient outcomes and disease management.	O	O	O	O	O
1c. Identify opportunities to address gaps in knowledge via future research efforts.	O	O	O	O	O
1d. Describe how insights from sex and gender research in one disease area can inform research design in other fields of study.	O	O	O	O	O

2. Please evaluate the overall effectiveness of the activity:

• Extremely effective

• Very effective

• Moderately effective

• Slightly effective

• Not at all effective

3. Please tell us how this activity could be improved: _____________________

4. Will this activity include your patients’ clinical outcomes?

• Yes

• No

• Not Applicable

5. Will you change your practice in any way as a result of participating in this activity?

• Yes

  • If yes, please specify ___________________

• No

• Not Applicable

6. Did you observe commercial bias in the activity?

• Yes

• No

7. How many minutes did it take you to complete the module?

• 0 – 30 minutes

• 31-60 minutes

• 61-90 minutes

• More than 90 minutes

8. What topics would you like to see included in this or other educational activities?