Evaluation and CME Claim Form - SBAS 27th Annual Meeting April 27th - 29th 2017, Chicago, Illinois


To receive CME credits, this evaluation form must be completed and submitted by June 2, 2017.

Be sure to include your ACS membership number when indicated so your CME certificate may be transferred directly to your MY CME record on the ACS Portal. In addition, providing us with your ACS membership number will ensure proper credit is posted faster and to the correct page.
 
 
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1.  
Please enter your name
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2.  
Choose one
 
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3.  
Please enter your email address
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4.  
Are you a member of the American College of Surgeons?
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5.  
Please enter your ACS Membership Number
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6.  
AMA PRA Category 1 Credits 

The American College of Surgeons designates this live activity for a maximum of 10.50 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Of the AMA PRA Category 1 Credits listed above, a maximum of 7.75 credits meet the requirements for Self-Assessment. 
As a participant, I am claiming (enter below) hours of CME Credit.
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7.  
This activity has an optional Self-Assessment component. In order to earn Self-Assessment Credit, you must pass the post-test with a score of 75% or higher. *NOTE: 15 minutes of session attendance = 0.25 AMA PRA category 1 credits.

As a participant of this educational activity, I am requesting (enter below) number of Self-Assessment hours.
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8.  
Please check the appropriate response for each statement using the following scale:

5= Excellent/Strongly Agree
4=  Very Good/ Agree
3= Good/ Neutral
2= Poor/Disagree
1= Very Poor/Strongly Disagree
Overall how would you rate this activity?

Program topics & content met the stated objectives.

Program content was relevant to my educational needs.

Educational format was conductive to learning.

Acquired knowledge will be applied in my practice environment.

I will seek additional information on this subject.

Program was fair, objective & unbiased towards any products or programs.

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9.  
Please explain any specific instance(s) of bias or conflict of interest. 
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10.  
Please list a minimum of two things you are going to change in your practice as a result of what you have learned at this activity.
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11.  
Please Describe the barriers anticipated when implementing the changes mentioned above.
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12.  
Please provide suggestions for future topics to support and / or expand on what you have learned at this activity.
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13.  
Please provide additional comments as it relates to this conference.