2008 Peer-to-Peer Dialogue - Attestation/Evaluation Form

Recognition and Diagnosis of HIT Session #5

Complete and submit this form to apply for 0.25 credit hours of AMA PRA Category 1 Credit™. Upon acceptance of this form by The France Foundation, you will receive a certificate documenting your successful completion of this activity. Please note that this entire form must be completed to receive credit.

Participant Information:

First Name:*

Last Name:*

Please Indicate Your Degree(s):*

Address:*

City:*

State/Province:*

ZIP/Postal Code:*

Email address:*

Clinician Type:*

If Other:

Number of years in practice:*

What percent of your patients are at risk for HIT?:*

Indicate the number of Credits you are claiming:
(May not exceed 0.25 credit)*

Met Learning Objective:

4-Strongly Agree 3-Agree 2-Disagree 1-Strongly Disagree

Upon completion of this activity, I will be able to:

Identify risk factors associated with HIT and describe criteria or current guidelines for early recognition and appropriate diagnosis of HIT.

Bias, Fair Balance:

Was this activity fair, balanced, objective,
and free from commercial bias?

If no, please state reason(s)

Practical Application:

4-Strongly Agree 3-Agree 2-Disagree 1-Strongly Disagree

I felt the format used in this activity was a beneficial method of learning.

This activity provided clinically relevant information.

What I learned in this activity will improve my ability to care for my patients with HIT.

List one thing you would do differently or incorporate into you clinical practice as a result of this educational activity:

Barriers:

What are the top 3 barriers you feel might inhibit your ability to incorporate any of the above changes into your clinical practice?

How Did You Come to Participate in this CME Activity?

HITeducation.com^™ CME Activity Participation

Prior to this activity, what is the approximate number of HITeducation.com^™ CME activities that you have participated in this calendar year?

After participating in this activity, how likely are you to participate in an HITeducation.com^™ CME activity in the future?