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© FMOQ | MAJ 12-2015
EVALUATION FORM (CONFERENCES)Please complete this questionnaire and hand it in before leaving. Thank you!
Direction de la formation professionnelle2, Place Alexis Nihon, 20e étage, 2000-3500 boulevard de Maisonneuve Ouest, Westmount (Québec) H3Z 3C1
Téléphone : 514 878-1911 | 1 800 361-8499 | Télécopieur : 514 878-4455 | Courriel : fmc.dc@fmoq.org | Site Web : www.fmoq.org
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Check the appropriate box: General practitioner Resident Other Specify: _____________________
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© FMOQ | MAJ 12-2015
EVALUATION FORM (CONFERENCES)
I would like to participate as a: Speaker Scientific director
Name and permit no.: _____________________________________________________________
Field of interest: _________________________________________________________________
The activity adhered to the code of ethics for CME presenters: (This code of ethics can be found at www.cqdpcm.ca)
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Relevant content
Objectives achieved
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Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
suite
© FMOQ | MAJ 12-2015
EVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
© FMOQ | MAJ 12-2015
suiteEVALUATION FORM (CONFERENCES)
Excellent Good Fair Poor
Relevant content
Objectives achieved
Clear presentation
Presenter’s communication skills
Interaction
Documentation
Disclosure of Conflicts of Interest Yes No
Commercial bias present Yes * No
Confirm my practice Changed my practice
* Commercial bias present, specify: __________________________________________________________
Topic(s) and presenter(s) :Topic: _____________________________ Presenter: _____________________________________
Comments: ________________________________________________________________________
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