NMNA CNE Evaluation Summary Report

This summary must be kept in the provider’s files, with the appropriate application documentation. Within 14 days of your educational activity, Email this report as an attachment to . You may discard participant’s evaluations once this report is completed and filed.

Please do your own math:

  1. total the number of points from the evaluations for each individual objective and presenter.
  2. Divide those totals by only the number of participants who answered that particular point.

Each and every objective AND/OR Purpose Statement, and each and every presenter MUST be evaluated separately and the exact objectives typed onto this form if evaluating on objectives.

CNE Approval Code:

Provider:

CNE Title:

Date(s) of activity:

Total number of participants in this activity (learners): ______

Was this continuing nursing education activity jointly provided? __ No __ Yes

If Yes, what other entity(s) involved? Name(s) of organization(s): ______

______

Did you receive commercial support from Commercial Entities*? If so, list supporters and the amount of money provided or in-kind support by each: *Commercial entities are manufacturers or re-sellers of drugs, devices, other items used by or on patients. It does not include universities, colleges, federal or state grantors, purveyors of software, etc.

Name of organizationFunding

______

______

______

______

______

Name of person completing summaryDate

Please note: we must receive a copy of Sign-In sheet for participants registered for the activity. This can be scanned and sent electronically.

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Title of Educational Activity:______

Circle the number that best fits your evaluation of this activity. 4= Completely3=Almost Completely2= Somewhat 1 = Not at all

1The overall LearningOutcome of this activity was met: [insert Learning Outcome]:

1234

3.. Rate the expertise / effectiveness of each presenter individually:

a.#1 presenter name1234

b.#2 presenter name1234

c. #3 presenter name1 234

Repeat for all presenters

4. Overall, were the teaching methods/ strategies effective?1234

5. The following were disclosed prior to the beginning of this activity in writing?

  1. Requirements for successful completionYesNo
  2. Learning OutcomeYesNo
  3. Conflicts of interest or no Conflicts of Interest disclosed?YesNo
  4. Commercial supportYesNo

If you do have commercial support, include non-endorsement statement:

If you were taught a new skill, procedure or national standard, how will you implement this in your work setting?

______

What barriers might you encounter in this implementation?______

Did you, as a participant, notice any commercial bias that was not previously disclosed in this presentationYesNo

If yes, please describe who was biased and how:______

If you answered (1) or (2) to any of the above, please comment:______

Comments or suggestions for this training or future trainings

The following is for you, the provider, to add your comments.

Summarize your findings regarding the effectiveness of this CNE Activity, including problems encountered (and how you will avoid this problem in the future) response of audience to faculty, and list all comments made by faculty, planners, and audience:

______

If you had a post-test, what were the average scores for the items on the test, and what percentage of learners passed the post-test?

If you are evaluating long-term for changes in practice or performance data, how effective was this activity in changing practice or performance data.