BMW One-Day Workshops – CME Evaluation CME Evaluation Form - BMW One-Day Workshops - 2016 - Non-Social Work Please complete the form below to claim your CME. Name * First and Last Name (This is the name that will appear on your CME Certificate) Credentials Practice/Organization * Email Address * Phone Number * Address * Address 2 City * State * ------AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Specialty * Primary Care Medical Subspecialty Surgeon Hospitalist Urgent Care OtherOther How can the Ohio AAP Assist in meeting your education needs? * Please select the BMW One-Day Workshop that you attended: February 19, 2016 March 4, 2016 May 17, 2016 June 7, 2016 August 19, 2016 At the conclusion of this activity, are you able to: Demonstrate confidence and competence in communication skills that support a therapeutic alliance with children and families affected by mental health issues? * Yes No Implement evidence-based strategies for assessment and treatment of common mental health conditions, including anxiety, depression, inattention and impulsivity? * Yes No Implement screening tools for assessment and treatment of common mental health conditions, including postpartum depression screening, family environment screening, adolescent depression screening, and substance use screening? * Yes No Utilize quality improvement resources to develop an aim statement and define an initial PDSA cycle focused on implementation of behavioral/mental health screening tools? * Yes No On a scale of 1-5, with 1 being Strongly Disagree and 5 being Strongly Agree, please rate the following statements. The content matched my current or potential scope of practice. * 1 2 3 4 5 The speaker was knowledgeable and able to effectively teach the content. * 1 2 3 4 5 As a result of participating in this learning activity, do you intend to make changes in your practice? * Yes No If yes to the previous question: Please describe what you will do differently in practice [performance]. How will you accomplish this change in practice [competence]? How would you rate your overall satisfaction with this activity? * Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied Please enter the amount of credit that you are claiming for this activity - maximum of 6.5 hours. * .51.01.52.02.53.03.54.04.55.05.56.06.5 You may only claim credit that is commensurate with your participation in the activity. Are you a physician that is planning to participate in the BMW Online MOC Part IV? Yes No We will follow-up with all interested individuals with information about registering for a Technical Assistance Webinar. By signing or typing your name, you confirm your identity and agree to the conditions and disclosures of this survey. * Clear If you are human, leave this field blank.
