QP

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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.

Q1.1	Now that you have participated in this activity, how confident are you in your ability to distinguish the treatment of hemophilia from the treatment of hemophilia with an inhibitor?
		1-Not confident
		2
		3
		4
		5
		6-Very confident

Q1.2	What level of factor activity is observed in patients classified as having severe hemophilia?
		<1%
		5%
		10%
		15%
		Unsure

Q1.3	Hemophilia accounts for _____ of total drug costs for patients with >/=$1M in annual prescription claims.
		3.6%
		7.3%
		10.4%
		14.7%
		Unsure

Q1.4	Now that you have participated in this activity, how confident are you in your ability to engage patients with hemophilia to enhance self-monitoring and promote therapeutic adherence?
		1-Not confident
		2
		3
		4
		5
		6-Very confident

Q1.5	Within your plan or practice setting when applicable, how often do you plan to require and/or recommend that patients with hemophilia receive treatment from at a facility with an integrated care model such as a hemophilia treatment center (HTC), especially those individuals with inhibitors or at risk for developing inhibitors?   (1 = Never, 6 = Always) (Please select the appropriate number on the scale below or mark if this decision or authority is outside your usual scope of practice)
		1-Never
		2
		3
		4
		5
		6-Always
		Not within my scope of practice

Evaluation Form Medical Education Resources, Inc. 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.

Q1.6	What is your specialty?
		Pharmacist
		MD/DO
		NP
		RN
		Case Manager
		Other

	Q1.6o. Please explain "other".

Q1.7	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

	Q1.7o. Please explain "other".

Q1.8	How many years have you been in your area of responsibility?
		Under 5
		5 to 10
		11 to 20
		Over 20

Q1.9	Approximately how many patients with hemophilia are being managed in your organization, practice setting, or affiliated organizations?
		1 to 5
		6 to 10
		11 to 20
		21 to 50
		51 to 100
		101 to 200
		N/A

Q1.10	Rate how well the activity supported your achievement of these learning objectives.
		Strongly disagree		Disagree		Neutral		Agree		Strongly agree
	Describe recent insights into the safety, efficacy, and attributes of recently approved and emerging hemophilia treatment options
	Review alignment of recently approved therapies in the current hemophilia treatment algorithm
	Explain hemophilia-related complications associated with inhibitor development and its significant clinical and economic consequences
	Apply processes for managed care and specialty pharmacy professionals to improve communications and collaborations with HTCs

Q1.11	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
	Shannon Carpenter,  MD, MS
	Edmund Pezalla, MD, MPH
	Jeffrey Dunn, PharmD, MBA

Q1.12	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
	Shannon Carpenter,  MD, MS
	Edmund Pezalla, MD, MPH
	Jeffrey Dunn, PharmD, MBA

Q1.13	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)

Q1.14	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

Q1.15	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):

Q1.16	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 guidelines
		Choice of treatment/management approach
		Change in pharmaceutical therapy
		Change in current practice for referral
		Change in non-pharmaceutical therapy
		Change in differential diagnosis
		Change in diagnostic testing
		Other

	Q1.16o. Please specify "other".

Q1.17	How confident are you that you will be able to make your intended changes?
		Very confident
		Somewhat confident
		Unsure
		Not very confident

Q1.18	Which of the following do you anticipate will be the primary barrier to implementing these changes?
		Formulary restrictions
		Insurance/financial issues
		Time constraints
		Lack of multidisciplinary support
		System constraints
		Treatment-related adverse events
		Patient adherence/compliance
		Other

	Q1.18o. Please specify "other".

Q1.19	Was the content of this activity fair, balanced, objective, and free of commercial bias?
		Yes
		No

	Q1.19o. Please explain.

Q1.20	Please list any clinical issues/problems within your scope of practice you would like to see addressed in future educational activities.

Q1.21

Full name

Q1.22

Degree

Q1.23

Organization

Q1.24

Specialty

Q1.25

Street Address

Q1.26

City

Q1.27

State

Q1.28

Zip

Q1.29	Type of Credit
		CPE
		CME
		Non-physician
		None

Q1.30

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.