First Name
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Last Name
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Email Address
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Date:
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Today M-D-Y
Are you an Ascension employee or affiliated or credentialed with an Ascension hospital?
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Yes No
Which facility are you employed, affiliated or credentialed with?
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Which Ministry Market are you employed, affiliated or credentialed with?
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Ascension Indiana Ascension Michigan Ascension Tennessee Ascension Texas Ascension Wisconsin Ascension Alabama Ascension Florida Ascension Kansas/Oklahoma Ascension Amsterdam Ascension Baltimore/Washington Ascension Binghamton Ascension Bridgeport Ascension National Ascension AMITA
Which hospital are you employed, affiliated or credentialed with?
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St. Vincent Kokomo Hospital St. Vincent Indianapolis St. Vincent Neighborhood Hospital St. Vincent Women's Hospital St. Vincent Anderson Hospital St. Vincent Evansville St. Vincent Heart Center St. Vincent Carmel Hospital St. Vincent Fishers Hospital St. Vincent Randolph Hospital St. Vincent Jennings Hospital St. Vincent Williamsport St. Vincent Mercy Hospital St. Vincent Clay Hospital St. Vincent Salem Hospital St. Vincent Warrick St. Vincent Dunn Hospital
Which hospital are you employed, affiliated or credentialed with?
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Ascension Providence Rochester Hospital Ascension Borgess Hospital Ascension Borgess Lee Hospital Ascension Genesys Hospital Ascension St. John Providence Hospital - Novi campus Ascension St. John Providence Hospital - Southfield campus Ascension St. John Hospital Ascension St. John Macomb-Oakland Hospital - Madison Heights campus Ascension St. John Macomb-Oakland Hospital - Warren campus Ascension River District Hospital Ascension St. Joseph Hospital Ascension St. Mary's Hospital Ascension Standish Hospital
Which hospital are you employed, affiliated or credentialed with?
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Saint Thomas Rutherford Hospital Saint Thomas West Hospital Saint Thomas Midtown Hospital Saint Thomas Dekalb Hospital Saint Thomas River Park Hospital Saint Thomas Highlands Hospital Saint Thomas Stones River Hospital Saint Thomas Hospital for Specialty Surgery St. Thomas Hickman Hospital
Which hospital are you employed, affiliated or credentialed with?
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Ascension Providence Ascension Seton Medical Center Austin Dell Seton Medical Center Ascension Seton Smithville Ascension Seton Southwest Ascension Seton Northwest Ascension Seton Highland Lakes Ascension Seton Edgar B Davis Ascension Seton Williamson Ascension Seton Hays Dell Children's Medical Center of Central Texas
Which hospital are you employed, affiliated or credentialed with?
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Ascension Columbia St. Mary's - Ozaukee Ascension Columbia St. Mary's - Milwaukee Ascension St. Michael's Hospital Ascension St. Elizabeth Hospital Ascension Mercy Hospital Ascension St. Mary's Hospital Howard Young Medical Center Ascension St. Clare's Hospital Ascension Eagle River Hospital Ascension Our Lady of Victory Hospital Ascension Sacred Heart Hospital Ascension Calumet Hospital Flambeau Hospital Ascension Good Samaritan Hospital Ascension St. Francis Ascension All Saints Ascension Elmbrook Ascension Franklin Ascension St. Joseph Midwest Orthopedic Specialty Hospital Saint Elizabeth's Medical Center
Which hospital are you employed, affiliated or credentialed with?
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Providence Hospital St. Vincents East St. Vincents Birmingham St. Vincents St. Clair St. Vincent's Chilton St. Vincents Blount St. Vincent's Health System
Which hospital are you employed, affiliated or credentialed with?
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Sacred Heart Hospital Bay Medical Center Sacred Heart Hospital Emerald Coast Sacred Heart Hospital Gulf Coast Ascension St. Vincent's Riverside Ascension St. Vincent's Southside Ascension St. Vincent's Clay County
Which hospital are you employed, affiliated or credentialed with?
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Ascension Via Christi Hospital in Pittsburg Ascension Via Christi St. Francis Ascension Via Christi St. Joseph Ascension Via Christi Hospital in Manhattan Ascension Via Christi St. Teresa Wamego Health Center Jane Phillips Memorial Medical Center St. John Medical Center St. John Owasso St. John Broken Arrow Jane Phillips Nowata St. John Sapulpa
Which hospital are you employed, affiliated or credentialed with?
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St. Mary's Healthcare
Which hospital are you employed, affiliated or credentialed with?
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St. Agnes Hospital
Which hospital are you employed, affiliated or credentialed with?
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Our Lady of Lourdes Memorial Hospital
Which hospital are you employed, affiliated or credentialed with?
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St. Vincent's Medical Center
Which hospital are you employed, affiliated or credentialed with?
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AMITA Health Mercy Medical Center AMITA Health Resurrection Medical Center AMITA Health Saint Joseph Hospital, Chicago AMITA Health Saints Mary and Elizabeth Medical Center, Saint Elizabeth Campus AMITA Health Saints Mary and Elizabeth Medical Center, Saint Mary Campus AMITA Health Holy Family Medical Center AMITA Health Saint Joseph Hospital, Elgin AMITA Health Alexian Brothers Medical Center Elk Grove Village AMITA Health Rehabilitation Hospital Elk Grove Village AMITA Health Saint Francis Hospital AMITA Health St. Alexius Medical Center Hoffman Estates AMITA Health Women & Children's Hospital Hoffman Estates AMITA Health Alexian Brothers Behavioral Health Hospital Hoffman Estates AMITA Health Saint Joseph Medical Center AMITA Health St. Mary's Hospital
Identify which continuing education hours apply for you:
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MD DO PA NP CRNA RN PharmD RPh Pharmacy Tech Student PT OT Social Worker Chaplain Other
PHARMACY ONLY: NABP #
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PHARMACY ONLY: DOB (Month/Day)
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Did the speaker(s) meet each of the objectives?
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Yes No
What change(s) do you plan to make in your practice and/or department as a result of this CE/CME activity?
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What new team strategies will you employ as a result of this activity?
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How will your role in the collaborative team change as a result of this activity
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Did the information presented reinforce and/or improve your current skills?
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Yes No
Do you perceive any barriers in applying these changes?
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Speakers knowledge of Subject Matter
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Excellent Good Average Poor
Quality of Presentation & Handouts
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Excellent Good Average Poor
Overall activity
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Excellent Good Average Poor
Did the speaker provide an opportunity for questions and discussion?
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Yes No
Did you perceive commercial bias or any commercial promotional products displayed or distributed.
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Yes No
What I learned in this activity has increased my confidence in improving patient outcome results.
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Yes No
Do you plan to share information learned with other members of your practice team?
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Yes No
I will apply the knowledge and/or skills gained during this activity in my work:
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Yes No
What other CE/CME topic(s) would you like to attend?
Why is a producer necessary for virtual education? (select all that apply)
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A virtual training class:
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Is basically a one-way presentation with little or no audience participation
Has the fewest number of participants and the greatest amount of interactivity
Is any education that takes place virtually
More images (and less text) in your Google Slides are important because:
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We cannot read and listen at the same time
Finding the right picture is easier than finding the right words
Images are important because they decorate your presentation
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