Evaluation (Completion of this form is mandatory)
MDNJ1525
Please read the following questions and choose the most appropriate answer for each course completed. 1. Was the course content new or review? 2. How much time did you spend on this activity, including the questions? (Physicians should only claim credit commensurate with the extent of their participation in the activity.) 3. Would you recommend this course to your peers? 4. Did the course content support the stated course objective? 5. Did the course content demonstrate the author’s knowledge of the subject? 6. Was the course content free of bias? 7. Before completing this course, did you identify the necessity for education on the topic to improve your professional practice? 8. Have you achieved all of the stated learning objectives of this course? 9. Has what you think or feel about this topic changed? 10. Did evidence-based practice recommendations assist in determining the validity or relevance of the information? 11. Are you more confident in your ability to provide patient care after completing this course? 12. Do you plan to make changes in your practice as a result of this course content? 13. May we contact you later regarding planned changes in your practice and changes in treatment or health status of your patients as a result of this activity? To receive continuing education credit, completion of this Evaluation is mandatory. Last Name ____________________________________________ First Name _ ___________________________________ MI _ _____ State ____________________________ License # _______________________________________ Expiration Date _ _____________
1. New Review 2. _____ Hours 3. Yes MDNJ02EL 2 Credits
1. New Review 2. _____ Hours 3. Yes MDNJ01SO 1 Credit
1. New Review 2. _____ Hours 3. Yes MDNJ04MH 4 Credits
1. New Review 2. _____ Hours 3. Yes MDNJ08SU 8 Credits
No No No No No No No No No No No
No No No No No No No No No No No
No No No No No No No No No No No
No No No No No No No No No No No
4. Yes 5. Yes 6. Yes 7. Yes 8. Yes 9. Yes 10. Yes 11. Yes 12. Yes 13. Yes
4. Yes 5. Yes 6. Yes 7. Yes 8. Yes 9. Yes 10. Yes 11. Yes 12. Yes 13. Yes
4. Yes 5. Yes 6. Yes 7. Yes 8. Yes 9. Yes 10. Yes 11. Yes 12. Yes 13. Yes
4. Yes 5. Yes 6. Yes 7. Yes 8. Yes 9. Yes 10. Yes 11. Yes 12. Yes 13. Yes
MDNJ02EL - Assessment and Management of Pain at the End of Life — If you answered YES to question #12, how specifically will this activity enhance your role as a member of the interdisciplinary team? ________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ MDNJ01SO - Developing a Safe Opioid Treatment Plan for Managing Chronic Pain — If you answered YES to question #12, how specifically will this activity enhance your role as a member of the interdisciplinary team? ___________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ MDNJ04MH - Maternal Health Disparities — If you answered YES to question #12, how specifically will this activity enhance your role as a member of the interdisciplinary team? __________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ MDNJ08SU - Substance Use Disorders and Pain Management: MATE Act Training — If you answered YES to question #12, how specifically will this activity enhance your role as a member of the interdisciplinary team? ___________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
Signature required to receive continuing education credit.
Signature _________________________________________________________________________________
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MDNJ1525
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