2009 Peer-to-Peer Dialogue - Attestation/Evaluation Form

Session #1

Complete and submit this form to apply for 0.25 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):*
MD/DO PharmD/RPh NP
RN PA Other:

Address:*
City:*
State/Province:*
ZIP/Postal Code:*
Email address:*
Clinician Type:*

Hospitalist Critical Care Specialist
Critical Care Nurse General Surgeon
Health System Pharmacist Oncologist
Other

If Other:
Number of years in practice:*
≤ 5 6-10 11-15
16-20 21-25 > 25

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

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

Bias, Fair Balance: Was this activity fair, balanced, objective,
and free from commercial bias? Yes No If no, please state reason(s)

Practical Application: 4-Strongly Agree 3-Agree 2-Disagree 1-Strongly Disagree What I learned in this activity has increased my confidence regarding the appropriate use of pharmacotherapies in the management of patients with venous thromboembolism (VTE).
4 3 2 1

What I learned in this activity has improved my ability to assess and manage venous thromboembolism in my patients 4 3 2 1

What I learned in this activity will result in an improvement in my patients' health. 4 3 2 1

Do you intend to make changes or apply new information to your practice as a result of this activity?
Yes, I plan to make changes*
I'm not sure, but I'm considering changes*
No, I already practice these recommendations

*If yes or you are considering changes, please check off what you intend to do differently or incorporate into your clinical practice as a result of this educational activity
Use a standardized tool for evaluating patients for VTE risk (specify):
Use ACCP VTE Guidelines to help evaluate and manage patients at risk for VTE
Work within my institution to improve mechanisms for reducing thromboembolic risk(specify):
Other, please list:

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

Met Learning Objective: 4-Strongly Agree 3-Agree 2-Disagree 1-Strongly Disagree Upon completion of this activity, I will be able to: List the risk factors for VTE and how to assess overall risk in each hospitalized patient. 4 3 2 1

How Did You Come to Participate in this CME Activity? Direct Mail Colleague Web Search E-mail Advertisement

VTEeducation.com^™ CME Activity Participation Prior to this activity, what is the approximate number of VTEeducation.com^™ CME activities that you have participated in this calendar year? 0 1-3 4-6
7-9 > 10

After participating in this activity, how likely are you to participate in an VTEeducation.com^™ CME activity in the future? Very Likely Likely
Unlikely Unsure