RSS Title: / Date:
Topic/Speaker:
Session Objectives: / .

In order to receive CME credit, you must complete the session evaluation,

sign and return this form to the RSS Coordinator upon your departure.

ACCREDITATION STATEMENT

Beth Israel Medical Center and St. Luke’s and Roosevelt Hospitals are accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT

Beth Israel Medical Center designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits TM.

Physicians should only claim the credit commensurate with the extent of their participation in the activity.

I ATTEST THAT I HAVE EARNED / CATEGORY 1 AMA/PRA CREDIT FOR ATTENDING THIS SESSION
PRINT YOUR NAME
(IF ILLEGIBLE, WE WILL BE UNABLE TO PROVIDE CREDIT)
SIGNATURE

·····································(Coordinator, please detach and submit evaluation form to the Course Director)···································

Regularly Scheduled Series (RSS) Session Evaluation

1. List at least onespecific practice change/application you plan to make based on this session.

2. If you do not plan to make any changes as a result of attending this session, what are the barriers?

I already perform the practices discussed in this session, OR

Barriers that prevent me from making suggested changes are:

3. Were the sessions evidenced-based, balanced and free of commercial bias? Yes No

If no, please explain:

4. Suggestions for future topics (and specific cause of the problem) that will enhance your competence, performance or patient outcomes)

CME CREDIT WILL NOT BE ISSUED

UNLESS THIS FORM HAS BEEN COMPLETED