CME Evaluation Form


February 2012


This Continuing Medical Education (CME) Evaluation Form and the CME Quiz on page 39 must be faxed or postmarked within a year of publication of this issue. To earn up to 1 hour of CME credit in medical ethics and/or professional responsibility, read the articles designated for CME credit and mark your responses on this evalua- tion form. You must complete parts 1, 2, 3, and 4 to receive credit. Mail or fax this page and the CME Quiz to the address or fax number listed at the bottom. There is no charge for this CME activity. Your certificate awarding 1 hour of AMA PRA Category 1 credit™ will be available on the TMA website at www.texmed.org (select “Education” and then “Your CME Transcript”). Please allow up to four weeks for your certificate to be available.


Part 1. Respond to each statement for the articles by filling in the appropriate box:


Educational value: I learned something new that was important. I verified some important information. I plan to seek more information on this topic. This information is likely to have an impact on my practice. The content was free of commercial bias.


Strongly agree


5 4 3


Strongly disagree


2 1


Readability feedback: I understood what the authors were trying to say. Overall, the presentation of the article enhanced my ability to read and understand it. Additional comments: _________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________


5 4 3 2 1


Part 2. Commitment to change: What change(s) (if any) do you plan to make in your practice as a result of reading these articles? ________________________________________________________________________


___________________________________________________________________________________________


Part 3. Statement of completion: I attest to having completed the CME activity. The time I spent was ____ hour(s), _____ minutes.


Sign here ____________________________________________________________ Date:_________________ Part 4. Identifying information: Please PRINT legibly or type the following:


Name______________________________________________________________________________________ Address:______________________________________ City:________________ State: ___ Zip: ___________ Telephone:____________________________________ Fax:________________________________________ E-mail:________________________ Member ID No. (located on magazine mailing label): _____________________


Where to send the completed CME Evaluation Form and CME Quiz Mail to Texas Medicine, Texas Medical Association, 401 W. 15th St., Austin, TX 78701; or fax to (512) 370-1629.


38 TEXAS MEDICINE February 2012


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