Pain Rounds Feedback

Please use this form to provide feedback on the Pain Rounds.

Speakers Name *

Title of Presentation

Date *

Your Name (required for CME Credit)

How would you rate this presentation? *

Very Poor	Poor	Fair	Good	Excellent
Very PoorItem #1 Very Poor	PoorItem #1 Poor	FairItem #1 Fair	GoodItem #1 Good	ExcellentItem #1 Excellent

Please rate the following statements *

	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	Not applicable
The objectives were clearly stated?	Strongly DisagreeThe objectives were clearly stated? Strongly Disagree	DisagreeThe objectives were clearly stated? Disagree	UndecidedThe objectives were clearly stated? Undecided	AgreeThe objectives were clearly stated? Agree	Strongly AgreeThe objectives were clearly stated? Strongly Agree	Not applicableThe objectives were clearly stated? Not applicable
The objectives were met?	Strongly DisagreeThe objectives were met? Strongly Disagree	DisagreeThe objectives were met? Disagree	UndecidedThe objectives were met? Undecided	AgreeThe objectives were met? Agree	Strongly AgreeThe objectives were met? Strongly Agree	Not applicableThe objectives were met? Not applicable
Topic met your CME needs?	Strongly DisagreeTopic met your CME needs? Strongly Disagree	DisagreeTopic met your CME needs? Disagree	UndecidedTopic met your CME needs? Undecided	AgreeTopic met your CME needs? Agree	Strongly AgreeTopic met your CME needs? Strongly Agree	Not applicableTopic met your CME needs? Not applicable
You acquired new knowledge?	Strongly DisagreeYou acquired new knowledge? Strongly Disagree	DisagreeYou acquired new knowledge? Disagree	UndecidedYou acquired new knowledge? Undecided	AgreeYou acquired new knowledge? Agree	Strongly AgreeYou acquired new knowledge? Strongly Agree	Not applicableYou acquired new knowledge? Not applicable
You will alter your current practice?	Strongly DisagreeYou will alter your current practice? Strongly Disagree	DisagreeYou will alter your current practice? Disagree	UndecidedYou will alter your current practice? Undecided	AgreeYou will alter your current practice? Agree	Strongly AgreeYou will alter your current practice? Strongly Agree	Not applicableYou will alter your current practice? Not applicable
The presentation was well prepared with effective A/V aids?	Strongly DisagreeThe presentation was well prepared with effective A/V aids? Strongly Disagree	DisagreeThe presentation was well prepared with effective A/V aids? Disagree	UndecidedThe presentation was well prepared with effective A/V aids? Undecided	AgreeThe presentation was well prepared with effective A/V aids? Agree	Strongly AgreeThe presentation was well prepared with effective A/V aids? Strongly Agree	Not applicableThe presentation was well prepared with effective A/V aids? Not applicable
The communication of ideas was clear and effective?	Strongly DisagreeThe communication of ideas was clear and effective? Strongly Disagree	DisagreeThe communication of ideas was clear and effective? Disagree	UndecidedThe communication of ideas was clear and effective? Undecided	AgreeThe communication of ideas was clear and effective? Agree	Strongly AgreeThe communication of ideas was clear and effective? Strongly Agree	Not applicableThe communication of ideas was clear and effective? Not applicable
The presenter was knowledgeable about the topic?	Strongly DisagreeThe presenter was knowledgeable about the topic? Strongly Disagree	DisagreeThe presenter was knowledgeable about the topic? Disagree	UndecidedThe presenter was knowledgeable about the topic? Undecided	AgreeThe presenter was knowledgeable about the topic? Agree	Strongly AgreeThe presenter was knowledgeable about the topic? Strongly Agree	Not applicableThe presenter was knowledgeable about the topic? Not applicable
There was sufficient time for discussion?	Strongly DisagreeThere was sufficient time for discussion? Strongly Disagree	DisagreeThere was sufficient time for discussion? Disagree	UndecidedThere was sufficient time for discussion? Undecided	AgreeThere was sufficient time for discussion? Agree	Strongly AgreeThere was sufficient time for discussion? Strongly Agree	Not applicableThere was sufficient time for discussion? Not applicable

Comments (topics discussed, strengths, weaknesses)