DocExecutive

Confidential CME Evaluation Form for Leadership Building for Women in Medicine

September 10, October 8, November 5, December 3, and January 7, 2025

Please take the time to complete this evaluation. Feedback about your experience is so important to us as we strive to make life less complex for every Woman in Medicine.

Thank you!

1. Did this activity meet the stated objectives?

2. Will this activity enhance your competence?

If you answered yes, please list examples.

3. Will this activity influence your practice?

If you answered yes, please list examples.

4. As a result of this activity, list one or two things that you plan to change in your practice.

5. Will this activity impact your patient outcomes??

If you answered yes, please list examples.

6. Was potential faculty conflict of interest (disclosure) provided to the audience prior to the activity?

7. If this event had commercial support, was the information provided to the audience?

8. Was the presentation free from commercial/personal bias for or against a product and/or company?

If you answered no, what was the bias?

10a. Speaker Evaluation - Lisa Belise, M.D.

Presentation skills.

10b. Speaker Evaluation - Lisa Belise, M.D.

Knowledge of topic.

10c. Speaker Evaluation - Lisa Belise, M.D.

Quality of handout(s).

10d. Speaker Evaluation - Lisa Belise, M.D.

Quality of Audio/Visuals.

10e. Speaker Evaluation - Lisa Belise, M.D.

Overall impression.

10f. Speaker Evaluation - Lisa Belise, M.D.

Please add any comments below.

11. Suggestions and/or topics for future programs.

Please add any comments below.

12. Please use the following to claim the number of credit hours:

If you have completed the entire activity claim 12 AMA PRA Category 1 Credit(s)TM. If you are an MD or DO and claim only partial AMA PRA Category 1 Credit(s)TM for this activity, please insert the number of credit hours you are claiming: 1 hour = 1 AMA PRA Category 1 CreditTM. If you are a non-physician and participated in this activity, please insert the number of hours in 15-minute increments. 15 minutes = .25 hours; 60 minutes = 1 hour. If you do not wish to claim AMA PRA Category 1 Credits™ or participation hours for this activity, please enter 0 below.

13. Please provide your name, License ID including State, email and credit hours claimed.

AMA Designation Statement

The Maine Medical Education Trust designates this live activity for a maximum of 12 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Joint Providership Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Maine Medical Education Trust and DocExecutive. The Maine Medical Education Trust is accredited by the Maine Medical Association Committee on Continuing Medical Education and Accreditation to provide continuing medical education for physicians.