1 Start 2 Complete

Learner Demographics *

Physician

Nurse

Other

Overall Series Rating *

	Excellent	Satisfactory	Poor
Overall, how would you rate this series?	Overall, how would you rate this series? - Excellent	Overall, how would you rate this series? - Satisfactory	Overall, how would you rate this series? - Poor

Extent to which identified Series objectives were met: I am better able to ... *

	Outstanding	Good	Satisfactory	Fair	Poor
Discuss treatment challenges.	Discuss treatment challenges. - Outstanding	Discuss treatment challenges. - Good	Discuss treatment challenges. - Satisfactory	Discuss treatment challenges. - Fair	Discuss treatment challenges. - Poor
Identify higher risk patients that need quick/timely consult.	Identify higher risk patients that need quick/timely consult. - Outstanding	Identify higher risk patients that need quick/timely consult. - Good	Identify higher risk patients that need quick/timely consult. - Satisfactory	Identify higher risk patients that need quick/timely consult. - Fair	Identify higher risk patients that need quick/timely consult. - Poor
Assess patient outcome from previous recommendation.	Assess patient outcome from previous recommendation. - Outstanding	Assess patient outcome from previous recommendation. - Good	Assess patient outcome from previous recommendation. - Satisfactory	Assess patient outcome from previous recommendation. - Fair	Assess patient outcome from previous recommendation. - Poor
Identify patients that may benefit from trial enrollment.	Identify patients that may benefit from trial enrollment. - Outstanding	Identify patients that may benefit from trial enrollment. - Good	Identify patients that may benefit from trial enrollment. - Satisfactory	Identify patients that may benefit from trial enrollment. - Fair	Identify patients that may benefit from trial enrollment. - Poor
Discuss possible barriers and biases which may impact patient care (i.e., race, ethnicity, language, gender identity/orientation, age, socioeconomic status, attitudes, feelings, or other characteristics).	Discuss possible barriers and biases which may impact patient care (i.e., race, ethnicity, language, gender identity/orientation, age, socioeconomic status, attitudes, feelings, or other characteristics). - Outstanding	Discuss possible barriers and biases which may impact patient care (i.e., race, ethnicity, language, gender identity/orientation, age, socioeconomic status, attitudes, feelings, or other characteristics). - Good	Discuss possible barriers and biases which may impact patient care (i.e., race, ethnicity, language, gender identity/orientation, age, socioeconomic status, attitudes, feelings, or other characteristics). - Satisfactory	Discuss possible barriers and biases which may impact patient care (i.e., race, ethnicity, language, gender identity/orientation, age, socioeconomic status, attitudes, feelings, or other characteristics). - Fair	Discuss possible barriers and biases which may impact patient care (i.e., race, ethnicity, language, gender identity/orientation, age, socioeconomic status, attitudes, feelings, or other characteristics). - Poor

Do you believe the subject matter presented/discussed was: *

	Yes	No
Objective	Objective - Yes	Objective - No
Fair & Balanced	Fair & Balanced - Yes	Fair & Balanced - No
Free of Commercial Bias	Free of Commercial Bias - Yes	Free of Commercial Bias - No

Have you made changes to your practice as a result of this series?

Yes

No

Please describe:

Do you have any recommendations for the moderator(s)/facilitator(s) of this series?

Yes

No

Please describe:

The Series included educational components that addressed cultural linguistic competency and implicit bias

Yes

No

N/A (If a research or non-direct patient care series)

Outside of this activity, what additional topics would you like addressed in other educational opportunities?

Leave this field blank