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Ohio AAP Evaluations
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Annual Meeting 2022 Evaluation and Credit
CME Activity Evaluation Form
Ohio AAP Diversity and Demographic Survey
3 Month Follow Up Surveys
Annual Meeting 2022 Evaluation and Credit
CME Activity Evaluation Form
Ohio AAP Diversity and Demographic Survey
3 Month Follow Up Surveys
CME Activity Evaluation Form
CME Evaluation Form
CME Evaluation Form
Participant Contact Information
Name (First and Last)
*
Please enter your name as you prefer for it to appear on your CME certificate.
Credentials
Such as MD, RN, etc.; if not applicable, leave blank.
Practice or Organization
*
Email Address
*
Your CME certificate will be sent to this address.
Phone Number
*
Address
*
City
*
State
*
Zip
*
If seeking MOC Part 2 credit, please enter your ABP diplomate number:
If seeking MOC Part 2 credit, please enter your date of birth (MM/DD/YY):
End Year for Current MOC Cycle:
Specialty
Primary Care (Pediatrics)
Primary Care (Family Medicine)
Medical Subspecialty
Nursing or Allied Health
Community Health Worker
Home Visitor
Other
Activity Evaluation
Which activity are you claiming credit for?
*
Asthma Updates to Empower Care Teams, Patients and Families (12/2/22)
Female Health Triad PMP (12/9/22)
Identify, Improve, Educate: Addressing Lead exposure Risks in Primary Care (1/20/23)
Maternal Mental Health (3/28/23)
Spring Education Meeting (4/21/23)
As a result of participating in this learning activity, do you intend to make changes in your practice?
*
Yes
No
Please share on what changes you plan to make.
Please select the reason (or reasons) that you chose to access this activity:
MOC Part II Credit
CME Credit
Educational Content/Topic
Speaker
Other
Other
On a scale of 1 - 5, please rate the following statements.
( 1 = Strongly Disagree, 3 = Neutral, 5 = Strongly Agree)
The content matched my current or potential scope of practice.
*
1
2
3
4
5
The speaker was knowledgeable and able to effectively teach the content.
*
1
2
3
4
5
I was satisfied with this learning activity.
*
1
2
3
4
5
There was bias related to diversity, equity or inclusion in this presentation.
*
1
2
3
4
5
How can the Ohio AAP Assist in meeting your education needs?
At the conclusion of this activity, are you able to:
Review Global Initiative for Asthma (GINA).
*
Yes
No
Understand GINA stepwise asthma guidelines.
*
Yes
No
Utilize asthma action plans for treatment clarity for patients, families and their care team members.
*
Yes
No
Highlight updates made to GINA asthma guidelines in 2022.
*
Yes
No
What does GINA stand for?
*
Global Initiative National Asthma Association
Global Initiative for Asthma
Global Inclusive National Asthma Association
None of the above
TRUE or FALSE: Patients with apparently mild asthma are NOT at risk of serious adverse events
*
TRUE
FALSE
Which of the following are changes or clarifications in GINA 2022?
*
“Written” asthma action plans
Acute asthma in healthcare settings
Use of e-cigarettes is associated with increased risk of respiratory symptoms and asthma exacerbations
All of the above
# of CME Hours:
# of MOC Part II Points:
At the conclusion of this activity, are you able to:
Review components of the female athlete triad and be able to identify women at risk.
*
Yes
No
Describe how traits of the triad may influence injury risk.
*
Yes
No
Offer treatment recommendations for women with the female athlete triad.
*
Yes
No
# of CME Hours:
# of MOC Part II Points:
At the conclusion of this activity, are you able to:
Identify sources of lead and risks of lead exposure to children in Ohio.
Not at all
Adequately
Very well
Discuss quality improvement and EHR approaches to improving lead screening and addressing high lead levels.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Review available resources for communicating with patients and families about lead.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
As a result of participating in this learning activity, do you intend to make changes in your practice to incorporate new methods to address nutrition and activity with patients?
Yes
No
Please describe what you will do differently in practice [performance] and how you will accomplish this change in practice [competence].
At the conclusion of this activity, are you able to:
Explain vaccine safety, efficacy and risk/benefits to hesitant patients.
Strongly Agree
Agree
Neutral
Disagree
Strongle Disagree
Review best practices and strategies for increasing HPV vaccination rates.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Collaborate with school health clinics on joint vaccine and communication efforts.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
At the conclusion of this activity, are you able to:
Understand the demographics of adolescent births in the United States.
Strongly Agree
Agree
Neutral
Disagree
Strongle Disagree
Discuss risk factors and complications of adolescent pregnancies.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Management of perinatal depression and anxiety.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
As a result of participating in this learning activity, do you intend to make changes in your practice to incorporate new methods to address nutrition and activity with patients?
Yes
No
Please describe what you will do differently in practice [performance] and how you will accomplish this change in practice [competence].
Please describe your 90 day action plan for implementing strategies learned in the training.
Pediatrician and Practice Demographics
As a component of our commitment to Diversity Equity and Inclusion (DEI), the Ohio AAP is capturing data that will help us understand our current landscape and improve our education, programs and advocacy for our members and the children they serve. The Ohio AAP has based these questions on standards set by the National AAP; answering these questions is optional and your answers will not by shared or impact your participation in any activities.
Will you answer the demographic questions?
Yes
No
About your practice
Please describe the community in which your primary practice/position is located.
Rural
Suburban
Urban, inner-city
Urban, not inner-city
Which languages are most represented in your practice? (Check all that apply)
Arabic
English
French
Mandarin
Nepali
Portuguese
Spanish
Somali
Prefer not to answer
Other
Other
What racial or cultural group(s) describe your patient population? Select all that apply.
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latinx
Native Hawaiian/other Pacific Islander
White, non-Hispanic/Latinx
Other
Other
How many physicians are in your practice?
1
2
3-6
7-10
11-15
16+
Which best describes your primary employment setting, that is, the setting where you spend most of your time.
Pediatric practice with primary care only
Multispecialty practice with primary care only
Pediatric practice with primary and specialty care
Multispecialty practice with primary and specialty care
Specialty care practice with no primary care
Other
Other
Which best describes your primary employment setting, that is, the setting where you spend most of your time.
Privately owned practice
Health Maintenance Organization (staff model)
Medical school or parent university
Non-government hospital/clinic
Non-profit community health center (FQHC, etc)
City/county/state government hospital or clinic
US government hospital or clinic
Other
Other
Which types of providers are included in your practice? (Select all that apply)
Pediatricians
Family Medicine Physicians
APRN (including CNP)
Social Worker
Community Health Worker
Mental Health Specialist
Other Specialist(s) - please describe
Other Specialist(s) - please describe
About yourself
How long have you been practicing medicine?
< 6 years
6 - 10 years
11 - 15 years
16 - 20 years
> 20 years
What is your age?
< 31 years
31 - 40 years
41 - 50 years
51 - 60 years
> 60 years
What is your gender?
Agender
Female
Gender fluid
Male
Nonbinary
Trans Female
Trans Male
Prefer not to answer
Prefer to self describe
Prefer to self describe
With what racial or cultural group(s) do you identify? Select all that apply.
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latinx
Native Hawaiian/other Pacific Islander
White, non-Hispanic/Latinx
Prefer not to answer
Prefer to self describe
Prefer to self describe
Which languages are you capable of speaking fluently? (Check all that apply)
Arabic
English
French
Mandarin
Nepali
Portuguese
Somali
Spanish
Prefer not to answer
Other
Other
Which of the following best represents how you think of yourself?
Asexual
Bisexual
Gay
Lesbian
Pansexual
Straight/Heterosexual
Queer
Prefer not to answer
Prefer to self describe
Prefer to self describe
Signature
Clear
Credit Value
If you are human, leave this field blank.
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