Pharmacy & Therapeutics - March 2008 - (Page 179) CE Registration and Evaluation Form Date of publication: March 2008 Title: Pain Associated with Diabetic Peripheral Neuropathy: A Review of Available Treatments Authors: Erin L. St. Onge, PharmD, and Shannon A. Miller, PharmD Submission deadline: March 31, 2009 ACPE Program #079-000-08-015-HO4-P Pharmacy and Therapeutics A Peer-Reviewed Journal for Managed Care and Hospital Formulary Management Registration Name: Degree: Street address: Last 4 Digits of Social Security No. (Web ID): City: State: Zip: Telephone: E-mail Address: Check one: I Physician I Pharmacist I Other Time needed to complete this CE activity in hours: I 0.5 hr I 1 hr I 1.5 hr I 2 hr I Other Certification: I attest to having completed this CE activity. Signature (required) Date Answer Sheet Please fill in the box next to the letter corresponding to the correct answer 1. a I 2. a I 3. a I 4. a I 5. a I bI bI bI bI bI cI cI cI cI cI dI dI dI dI dI 6. a I 7. a I 8. a I 9. a I 10. a I bI bI bI bI bI cI cI cI cI cI dI dI dI dI dI Evaluation Rate the extent to which: 1. Objectives of this activity were met 2. You were satisfied with the overall quality of this activity 3. Content was relevant to your practice needs 4. Participation in this activity changed your knowledge/attitudes 5. You will make a change in your practice as a result of participation in this activity 6. This activity presented scientifically rigorous, unbiased, and balanced information 7. Individual presentations were free of commercial bias 8. Adequate time was available for Q&A I I I I I I I I I I I I I I I Very High I I I I I I High I I I I I I Moderate I I I I I I Low I I I I I I Very Low I I I I I I 9. Which ONE of the following best describes the impact of this activity on your performance: I This program will not change my behavior because my current practice is consistent with what was taught. I This activity will not change my behavior because I do not agree with the information presented. I I need more information before I can change my practice behavior. I I will immediately implement the information into my practice. 10. Will you take any of the following actions as a result of participating in this educational activity (check all that apply) I Discuss new information with other professionals I Discuss with industry representative(s) I Other I Consult the literature I Participate in another educational activity I None Send the completed form and $10 payment (make checks payable to P&T) to: Department of Health Policy, Thomas Jefferson University, Attn: Continuing Education Credit, 1015 Walnut Street, Suite 115, Philadelphia, PA 19107. Vol. 33 No. 3 • March 2008 • P&T® 179
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