Qp	Please enter the code provided at the event to proceed.

In an effort to better determine the overall effectiveness of continuing education activities, we are conducting a brief survey. Listed below are questions for which we would like your responses. All information obtained will be used and reported in aggregate only, without individual attribution. Thank you for your participation. If you have any questions please contact us at info@impactedu.net. *All questions are required.

Medical Education Resources (MER) is committed to excellence in continuing education, and your opinions are critical to us in this effort.  To assist us in evaluating the effectiveness of this activity and to make recommendations for future educational offerings, please take a few minutes to complete this evaluation form. You must complete this evaluation form to receive acknowledgment for completing this activity.

Q1.1	CMS coverage eligibility for continuous glucose monitoring (CGM) includes patients with which of the following characteristics?
		Intensive insulin-treated
		Non-intensive insulin-treated
		History of problematic hypoglycemia
		A & B
		All of the above
		Unsure

Q1.2	HbA1c outcomes associated with the use of CGM are unrelated to household income, insurance status, ethnicity, or age.
		True
		False
		Unsure

Q1.3	Within your practice and/or organizational setting, when applicable, how often do you plan to utilize and/or support the use of CGM to improve patient engagement for lifestyle change and behavior modification?
		6-Always
		5-Almost Always
		4-Frequently
		3-Sometimes
		2-Seldomly
		1-Never
		Not within my scope of practice

Q1.4	What is your specialty?
		Pharmacist
		MD/DO
		NP
		RN
		Case Manager
		Other

	Q1.4a. Please explain "other".

Q1.5	What best describes your primary role?
		Specialty Pharmacist		Case Manager		Pharmacy Director
		Student		Nurse		Quality Director or Associate
		Clinical Pharmacist		Managed Care Affiliated Physician/Clinician		CMS/Government Policy
		Pharmacy Consultant		Other Clinician		Other
		PBM Pharmacist		Medical Director

	Q1.5a. Please explain "other".

Q1.6	How many years have you been in your area of responsibility?
		Under 5
		5 to 10
		11 to 20
		Over 20

Q1.7	Approximately how many people with diabetes are being managed in your organization, practice setting, or affiliated organizations?
		1 to 250
		251 to 500
		501 to 1000
		1001 to 2000
		2001 to 5000
		Over 5000
		N/A

Q1.8	Rate how well the activity supported your achievement of these learning objectives.
		Strongly disagree		Disagree		Neutral		Agree		Strongly agree
	Assess clinical evidence and expert recommendations supporting the use of CGM in patients with type 1 and type 2 diabetes
	Characterize the value of rtCGM in improving diabetes outcomes via patient engagement and behavior modification
	Describe the role of managed care pharmacy professionals in facilitating appropriate CGM access and utilization

Q1.9	Please select the extent to which you agree/disagree that the speakers achieved the following: Effective in Presenting the Material
		Strongly disagree		Disagree		Neutral		Agree		Strongly agree
	Nicole Ehrhardt, MD
	Carly Rodriguez, PharmD, FAMCP
	Jeff Dunn, PharmD, MBA

Q1.10	Please select the extent to which you agree/disagree that the speakers achieved the following: Avoided Commercial Bias or Influence
		Strongly disagree		Disagree		Neutral		Agree		Strongly agree
	Nicole Ehrhardt, MD
	Carly Rodriguez, PharmD, FAMCP
	Jeff Dunn, PharmD, MBA

Q1.11	Rate how well the activity achieved the following.
		Strongly disagree		Disagree		Neutral		Agree		Strongly agree
	The content was evidence based
	The educational material provided useful information for my practice
	The activity enhanced my current knowledge base
	The activity provided appropriate and effective opportunities for active learning (eg, case studies, discussion, Q&A, etc)
	The opportunities provided to assess my own learning were appropriate (eg, questions before, during or after the activity)

Q1.12	This activity was designed to promote the core competencies for interprofessional collaborative practice.  Which of these competencies will you apply to enhance your interprofessional healthcare team?  (select all that apply)
		Values/ethics for interprofessional practice
		Roles and Responsibilities
		Interprofessional communication
		Teams and teamwork

Q1.13	Based upon your participation in this activity, do you intend to change your practice and/or administrative behavior?
		I do plan to implement changes in my practice and/or administrative routine based on the information presented
		My current practice and/or administrative routine has been reinforced by the information presented
		I need more information before I will change my practice and/or administrative routine

Q1.14	Thinking about how your participation in this activity will influence your patient care, how many of your patients in your practice or organization are likely to benefit? Please use a number (example 250):

Q1.15	If you plan to change your practice and/or administrative behavior, what type of changes do you plan to implement? (check all that apply)
		Apply latest evidence required for drug/device evaluations
		Apply latest pharmacoeconomic evaluation(s)
		Apply a collaborative care approach
		Change in drug/device benefit design
		Change in utilization management approach
		Change in formulary strategy
		Change in drug/device coverage policy
		Change in evidence-based decision making
		Change in care coordination approach
		Change in access to appropriate therapy
		Change in specialty pharmacy services
		Other

	Q1.15a. Please specify "other".

Q1.16	How confident are you that you will be able to make your intended changes?
		Very confident
		Somewhat confident
		Unsure
		Not very confident

Q1.17	Which of the following do you anticipate will be the primary barrier to implementing these changes?
		Financial issues
		Lack of departmental support
		Lack of interprofessional team support
		Organizational policy
		Patient adherence/compliance
		System constraints
		Time
		Other

	Q1.17a. Please specify "other".

Q1.18	Was the content of this activity fair, balanced, objective, and free of commercial bias?
		Yes
		No

	Q1.18a. Please explain.

Q1.19	Please list any clinical issues/problems within your scope of practice you would like to see addressed in future educational activities.

Q1.20

Full name

Q1.21

Degree

Q1.22

Organization

Q1.23

Specialty

Q1.24

Street Address

Q1.25

City

Q1.26

State

Q1.27

Zip

Q1.28	Type of Credit
		CPE
		CME
		Non-physician
		None

Q1.29

Email (IMPORTANT: Your certificate will be EMAILED to your email address)

FOR PHARMACISTS: Upon submission of your evaluation you will be redirected to a web page with instructions to submit your credit to CPE Monitor. You must follow the instructions to claim credit. If you have any questions please email info@impactedu.net.