Counseling Points Multiple Sclerosis - Spring 2015 - 15

Counseling Points™: Program Evaluation Form
Encouraging Monitoring and Follow-up in MS Care
Using the scale provided (Strongly Agree = 5 and Strongly Disagree = 1) please complete the program evaluation so that we may
continue to provide you with high-quality educational programming. Please fax this form to (201) 612-8282
or complete it online as instructed below.
5 = Strongly Agree 4 = Agree 3 = Neutral 2 = Disagree 1 = Strongly Disagree
At the end of this program, I was able to: (Please circle the appropriate number on the scale.)
1) Discuss current challenges associated with pre-treatment monitoring for MS disease-modifying therapies (DMTs) ................... 5 4 3 2 1
2) Assess methods for recommending and encouraging regular follow-up while on MS DMT ...................................................... 5 4 3 2 1
3) Review how appropriate monitoring can prevent complications of MS DMTs ........................................................................ 5 4 3 2 1
To what extent was the content:
4) Well-organized and clearly presented ........................................................................................................................................ 5 4 3 2 1
5) Current and relevant to your area of professional interest .......................................................................................................... 5 4 3 2 1
6) Free of commercial bias ............................................................................................................................................................ 5 4 3 2 1
7) Clear in providing disclosure information.................................................................................................................................. 5 4 3 2 1
General Comments
8) As a result of this continuing education activity (check only one):
r I will modify my practice. (If you checked this box, how do you plan to modify your practice?)_____________________________
____________________________________________________________________________________________________________________________

r I will wait for more information before modifying my practice.
r The program reinforces my current practice.
9) Please indicate any barriers you perceive in implementing these changes (check all that apply):
r Cost
r Lack of opportunity (patients)
r Patient adherence issues
r Other (please specify) ________
r Lack of administrative support r Reimbursement/insurance
r Lack of professional guidelines ___________________________
r Lack of experience
r Lack of time to assess/counsel patients r No barriers
___________________________

10) Will you attempt to address these barriers in order to implement changes in your knowledge, skills, and/or patients' outcomes?
r Yes. How? ________________________________________________________________________________________________________________
r Not applicable
r No. Why not? _____________________________________________________________________________________________________________
Suggestions for future topics/additional comments: ________________________________________________________________________________
___________________________________________________________________________________________________________________________________

Follow-up
As part of our continuous quality-improvement effort, we conduct postactivity follow-up surveys to assess the impact of our educational interventions on professional practice. Please check one:
r Yes, I would be interested in participating in a follow-up survey.
r No, I would not be interested in participating in a follow-up survey.
There is no fee for this educational activity.

Post-test Answer Key

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Request for Credit (Please print clearly)
Name _________________________________________________________________ Degree ________________________________________
Organization __________________________________________________________ Specialty ________________________________________
Address ________________________________________________________________________________________________________________
City _____________________________________________________________________________ State ____________ ZIP _________________
Phone _____________________________ Fax ____________________________ E-mail ____________________________________________
Signature ________________________________________________________________ Date _____________________________________
By Mail: Delaware Media Group, 66 S. Maple Ave., Ridgewood, NJ 07450
By Fax: (201) 612-8282
Via the Web: Applicants can access this program at the International Organization of MS Nurses' website, www.IOMSN.org.
Click on Educational Materials > Publications > Counseling Points and follow the instructions to complete the online post-test and application forms.

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Spring 2015
Counseling Points Multiple Sclerosis - Spring 2015

Table of Contents for the Digital Edition of Counseling Points Multiple Sclerosis - Spring 2015
