Evaluation: CHAMPS "Improving Diabetes Care through Group Visits and PCMH Principles"

1. Evaluation Introduction: Contact Information and Satisfaction

Thank you for attending "Improving Diabetes Care through Group Visits and Patient-Centered Medical Home (PCMH) Principles." This live and archived webcast was originally held on March 18, 2014 and was sponsored by CHAMPS.

Please complete the following evaluation questions so we can review our goals, objectives, and topics for future events. If you complete the Evaluation Questions and provide your contact information, you will receive a Certificate of Participation for this event within six weeks. If you complete the Evaluation and CME questions, you will receive a CME Certificate within six weeks.

Viewers of the live webcast: please complete and submit this Evaluation/CME information no later than Tuesday, March 25, 2014.

Question Title

* 1. Please provide your contact information. This is required if you would like to receive a Certificate of Participation or CME Credit for this event.

First Name

Last Name, Credentials

Title

Organization

Address

City, ST

ZIP

Email Address

Phone Number

Question Title

* 2. Are you requesting CME for this event?
(A $15 per person fee applies for persons working at organizations that are not Region VIII Health Center Program grantees, FQHC Look-Alikes, or Primary Care Associations.)

Yes

Question Title

* 3. Which version of this event ("Improving Diabetes through Patient-Centered Medical Home (PCMH) Principles") did you watch in advance of completing this Evaluation/Credit questionnaire?

Live Online Event (broadcast on 03/18/14)

Online Archive (not yet available)

CD Archive (not yet available)

Question Title

* 4. Please rate your overall satisfaction with this webcast on a scale of 1-10 (1 being the worst possible rating and 10 being the best possible rating).

	1 (worst possible)	2	3	4	5	6	7	8	9	10 (best possible)
Satisfaction	Satisfaction 1 (worst possible)	Satisfaction 2	Satisfaction 3	Satisfaction 4	Satisfaction 5	Satisfaction 6	Satisfaction 7	Satisfaction 8	Satisfaction 9	Satisfaction 10 (best possible)

Comments (optional)

Question Title

* 1. Please provide your contact information. This is required if you would like to receive a Certificate of Participation or CME Credit for this event.

Question Title

* 2. Are you requesting CME for this event? (A $15 per person fee applies for persons working at organizations that are not Region VIII Health Center Program grantees, FQHC Look-Alikes, or Primary Care Associations.)

Question Title

* 3. Which version of this event ("Improving Diabetes through Patient-Centered Medical Home (PCMH) Principles") did you watch in advance of completing this Evaluation/Credit questionnaire?

Question Title

* 4. Please rate your overall satisfaction with this webcast on a scale of 1-10 (1 being the worst possible rating and 10 being the best possible rating).

* 2. Are you requesting CME for this event?
(A $15 per person fee applies for persons working at organizations that are not Region VIII Health Center Program grantees, FQHC Look-Alikes, or Primary Care Associations.)