SIGN IN & OVERALL OBJECTIVES

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* 1. First Name

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* 2. Last Name

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* 3. Degree, exactly as you would like it to appear on your certificate (MD, PhD, etc)

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* 4. What email address would you like your certificate information to be sent?

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* 5. LEARNING OBJECTIVES

  Strongly Disagree Disagree Unsure Agree Strongly Agree
Identify the latest anesthesia techniques for ophthalmic surgery.
Review pertinent historical and anatomical information related to ophthalmic surgery.
Evaluate different anesthesia techniques to determine which might warrant a change in current practice.
Generate an increased or sustained interest in developing knowledge, acquiring skills and continuing education in the area of ophthalmic anesthesia.

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* 6. DISCLOSURE COMPLIANCE -- Please rate your level of agreement with the following statements.

  Strongly Disagree Disagree Unsure Agree Strongly Agree
Faculty disclosures and acknowledgements of commercial support were made.
There was no evidence of commercial bias in this activity.

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* 7. OBJECTIVITY AND RELEVANCE. Please rate your level of agreement with the following statements:

  Strongly Disagree Disagree Unsure Agree Strongly Agree
The content was objective and balanced.
The content was evidence-based.
Sources of evidence were identified.
The activity was relevant to my practice.
I will apply what I learned in this activity.

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* 8. Please list 3 specific things you will do differently as a result of participating in this activity:

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* 9. What additional practice-based topics would you like to be addressed in future activities?

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* 10. What is your highest degree?

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* 11. How long have you been in the health profession?

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* 12. I am willing to particpate in a post-activity outcomes assessment survey.

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