Advanced Care Planning in Primary Care: Tools for Success

Program Evaluation

We appreciate your participation in our continuing education activity. Your responses to this anonymous survey will allow us to improve our program offerings and services. Thank you for your time.

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* 1. What is your primary professional discipline?

Medicine

Rehab Therapy (PT/OT/SLP)

Nursing

Social Work

Pharmacy

Other

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* 2. Please list all professional license/certificate/degree(s) you hold:

EVALUATION OF TRAINING:
Please use the scale below to rate the efficacy of the learning objectives, the presenters, and the instructional format:
1 = Totally ineffective, wouldn't recommend
2 = Somewhat ineffective, at least one serious deficiency
3 = Somewhat effective, acceptable but not outstanding
4 = Effective, meets high standards, would recommend
5 = Highly effective, among the best

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* 3. Rate the relationship between activity content to stated learning objective:

	1	2	3	4	5
Identify the importance of having goals of care conversations	Identify the importance of having goals of care conversations 1	Identify the importance of having goals of care conversations 2	Identify the importance of having goals of care conversations 3	Identify the importance of having goals of care conversations 4	Identify the importance of having goals of care conversations 5
Describe the role of The Conversation Project in advance care planning	Describe the role of The Conversation Project in advance care planning 1	Describe the role of The Conversation Project in advance care planning 2	Describe the role of The Conversation Project in advance care planning 3	Describe the role of The Conversation Project in advance care planning 4	Describe the role of The Conversation Project in advance care planning 5
Describe when to use the different conversation starter kits	Describe when to use the different conversation starter kits 1	Describe when to use the different conversation starter kits 2	Describe when to use the different conversation starter kits 3	Describe when to use the different conversation starter kits 4	Describe when to use the different conversation starter kits 5
Identify ways to increase advance care planning in your practice	Identify ways to increase advance care planning in your practice 1	Identify ways to increase advance care planning in your practice 2	Identify ways to increase advance care planning in your practice 3	Identify ways to increase advance care planning in your practice 4	Identify ways to increase advance care planning in your practice 5

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* 4. Rate the effectiveness of the presenter(s)

	1	2	3	4	5
a. Presentation Style	a. Presentation Style 1	a. Presentation Style 2	a. Presentation Style 3	a. Presentation Style 4	a. Presentation Style 5
b. Knowledge of Subject	b. Knowledge of Subject 1	b. Knowledge of Subject 2	b. Knowledge of Subject 3	b. Knowledge of Subject 4	b. Knowledge of Subject 5
c. Quality of Material	c. Quality of Material 1	c. Quality of Material 2	c. Quality of Material 3	c. Quality of Material 4	c. Quality of Material 5
d. Practical applicability or relevance of topic	d. Practical applicability or relevance of topic 1	d. Practical applicability or relevance of topic 2	d. Practical applicability or relevance of topic 3	d. Practical applicability or relevance of topic 4	d. Practical applicability or relevance of topic 5

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* 5. Please rate the effectiveness of teaching strategies:

	1	2	3	4	5
Effectiveness of teaching strategies:	Effectiveness of teaching strategies: 1	Effectiveness of teaching strategies: 2	Effectiveness of teaching strategies: 3	Effectiveness of teaching strategies: 4	Effectiveness of teaching strategies: 5

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* 6. What was the most significant thing(s) you learned?

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* 7. In your work with older adults, do you intent to implement at least one practice improvement learned as a result of this activity?

Yes

N/A

If yes, please describe:

RETROSPECTIVE ASSESSMENT:
Use the following scale to rate your perceived level of confidence in the topics listed below BEFORE the training an AFTER the training. Scale: 1= not at all confident, 2= somewhat confident, 3= mostly confident 4= fully confident

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* 8. How confident were/are you in your ability to:

	Before	After
Identify the importance of having goals of care conversations	Identify the importance of having goals of care conversations Before menu	Identify the importance of having goals of care conversations After menu
Describe the role of The Conversation Project in advance care planning	Describe the role of The Conversation Project in advance care planning Before menu	Describe the role of The Conversation Project in advance care planning After menu
Describe when to use the different conversation starter kits	Describe when to use the different conversation starter kits Before menu	Describe when to use the different conversation starter kits After menu
Identify ways to increase advance care planning in your practice	Identify ways to increase advance care planning in your practice Before menu	Identify ways to increase advance care planning in your practice After menu

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* 9. Please feel free to share any additional comments and suggestions. Your feedback is extremely valuable to us.

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* 10. Please indicate what type of continuing education credit you are looking to obtain:

Nursing

Social Work

Certificate of attendance

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* 11. If you would like a Certificate of Completion/ Continuing Ed please complete the information below:

Name and Title

Organization

State

Email Address