Annual Wellness Visit Evaluation
Thank you for watching the
Annual Wellness Visit
webinar! After you successfully complete the evaluation and the reflective questions, you will access your certificate that includes continuing education credits. Thanks again!
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1.
Last Name
(Required.)
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2.
First Name
(Required.)
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3.
Email Address
(Required.)
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4.
Discipline
(Required.)
Nurse
Physician/Physician Assistant/Nurse Practitioner
Office Manager
Other Healthcare
Other
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5.
Organization Name
(Required.)
6.
CCN # (if applicable)
7.
NPI # (if applicable)
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8.
Zip Code
(Required.)
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9.
Select the best description of your work setting:
(Required.)
Physician Practices
Nursing Home
Community Care
Other (please specify)
Evaluation
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10.
Instructions:
Use the drop down boxes to rate your ability to demonstrate each of the following objectives
before
and
after
the education. If using mobile device, make sure to scroll to the right to see both columns.
(Required.)
BEFORE
AFTER
Identify Annual Wellness Visit (AWV) components
-- Select an option --
I have no confidence I can do this
I have a low level of confidence to do this
I am confident I can do it with assistance and/or more practice
I am confident I can do it on my own
I am confidence I can do it and help others to do it, as well
-- Select an option --
I have no confidence I can do this
I have a low level of confidence to do this
I am confident I can do it with assistance and/or more practice
I am confident I can do it on my own
I am confidence I can do it and help others to do it, as well
State who can conduct an AWV
-- Select an option --
I have no confidence I can do this
I have a low level of confidence to do this
I am confident I can do it with assistance and/or more practice
I am confident I can do it on my own
I am confidence I can do it and help others to do it, as well
-- Select an option --
I have no confidence I can do this
I have a low level of confidence to do this
I am confident I can do it with assistance and/or more practice
I am confident I can do it on my own
I am confidence I can do it and help others to do it, as well
Describe AWV assessments for nursing home residents
-- Select an option --
I have no confidence I can do this
I have a low level of confidence to do this
I am confident I can do it with assistance and/or more practice
I am confident I can do it on my own
I am confidence I can do it and help others to do it, as well
-- Select an option --
I have no confidence I can do this
I have a low level of confidence to do this
I am confident I can do it with assistance and/or more practice
I am confident I can do it on my own
I am confidence I can do it and help others to do it, as well
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11.
The presentation style of the speaker(s) contributed to my learning experience.
(Required.)
Yes
No
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12.
I will be able to apply what I learned on the job immediately using a scale of
1 (not at all)
to
5 (absolutely)
.
(Required.)
1 (not at all)
2
3
4
5 (absolutely)
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13.
Click on a star rating for your overall experience with this webinar course. (1 to 5 stars)
(Required.)
1 star
2 stars
3 stars
4 stars
5 stars
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14.
How are you going to integrate the Annual Wellness Visit components into your day-to-day practice to ensure they are complete?
(Required.)
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15.
Provide a short statement of the value of the Annual Wellness Visit that you could share with your patients/residents?
(Required.)
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16.
Who currently completes the Annual Wellness Visit at your practice/facility? Now knowing all the disciplines that can conduct the visit, will you add others?
(Required.)
17.
Other Comments:
