Sample Evaluation Form

CME EvaluationIndustry-supported Lecture-Learner ProgramsSections 1-3 to be completed by CME chair.Section 4 to be completed by each participant.1) Program InformationName of Program: ____________________________________________________________Date: ________________Time: _________________Location: _____________________________ Length of presentation: ____________________2) Grantor InformationName of corporation: __________________________________________________________3) Speaker InformationName: ______________________________________________________________________4) ObjectivityYesNoAre you aware of drugs/ products related 5 4 3 2 1to topic that are produced by the grantor?Did speaker present a balancedview of therapeutic options? 5 4 3 2 1Did you detect bias in favor of theproducts produced by the grantor? 5 4 3 2 1Were brand name(s) mentioned Yes Noduring presentation?If yes, which ones? ___________________________________________________________Did the speaker discuss unlabeled Yes Nouses of any products?If so, was it disclosed that Yes Nothey were unlabeled uses?Were relationships between grantor and Yes Nospeaker (e.g., payment of honorarium)announced prior to presentation?Continued on Reverse

Outstanding/ YesPoor/ NoPlease rate the following:1. Program content 5 4 3 2 12. Relevancy of content to your practice 5 4 3 2 13. Were explicit learning objectives stated? 5 4 3 2 14. Were learning objectives met? 5 4 3 2 15. Please rate the program overall. 5 4 3 2 16. As a result of this program, will you alter your practice? Yes No MaybeReviewed by:Signature (optional)