Form 4 Outcomes Evaluation

OMB # 0925-XXXX

Expiration Date: XX/XXXX

MODULE [COURSE] EVALUATION

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Outcomes survey

Dear Past Registrant:

We need your help to ensure that we are meeting your CME needs in the most effective manner possible. Please take a few minutes to complete this short survey. Although you may have answered similar questions as part of the activity evaluation, we are interested to know if, in the month since participating in the Internet Live Course, it has had a lasting impact on your practice.

1. Did the content and learning material address a need or a gap in your knowledge or skill of sex and gender differences in the presentation, risk factors, and pathophysiology of disease?

• Yes

(If Yes) 1a. Please describe how.

• No

2. Were there additional knowledge and/or skills that you would have liked to have gained as a result of completing the course?

• Yes

(If yes) 2a. Please provide specific examples.

• No

3. Since completing this course, have you engaged in conversations with your colleagues about how sex and gender differences in risk factors and pathophysiology affect patient outcomes and disease management?

• Yes

(If yes) 3a. Please provide specific examples.

• No

4. Please list the ways you have incorporated knowledge about sex- and gender-related differences into your practice.

5. Please identify how you will change your current work practices as a result of attending this activity (check all that apply).

• This activity validated my current work practices: no changes will be made.

• I will create/revise protocol, policies, and/or procedures.

• I will change the provision of my service to my patients, public, or profession.

• I will change my regulatory decision making

• Other (please explain)

6. Please indicate any barriers you perceive in implementing these changes (check all that apply).

• No barriers

• Lack of opportunity

• Lack of consensus of professional guidelines

• Budgetary constraints

• Lack of resources

• Lack of experience

• Lack of administrative support

• Other (please explain)

7. Please comment/explain what would be necessary for you to overcome the identified barrier(s) or what could be incorporated into this activity to address these barriers if you selected a response other than “No barriers” above

8. If there were barriers you could not overcome, use a specific example to explain what those were and what prevented you from overcoming them.

9. Did you perceive any commercial bias? Use the following criteria to judge:

9a. The content presented was balanced, evidence-based, demonstrated scientific rigor, and was without commercial bias.

• Yes

• No

(If no) Please explain:

9b. I was informed about the existence and resolution of relevant financial relationships/conflict of interests of course planners and authors prior to the presentation.

• Yes

• No

(If no) Please explain:

9c. Content that discussed off label, investigational, or alternative uses of products, devices or techniques disclosed as much in the presentation.

• Yes

• No

(If no) Please explain:

• Not applicable

10. Would you attend this activity in the future?

• Yes

• No

10. Would you recommend this activity to a colleague?

• Yes

• No