Conference Evaluation Form We would appreciate your opinions on the quality and usefulness of this conference. To receive proper credit for attending, all attendees must fill out this form for us to issue a certificate and to properly report credit hours for osteopathic physicians to the AOA. The AOA CCME requires that each physician certify or attest to the number of hours attended during a CME program.Upon completion, you will receive a copy of your completed evaluation form. Once your evaluation has been verified, your certificate will be issued to you.Fields marked with an asterisk * are required. Conference EvaluationPlease rate the following:*ExcellentVery GoodGoodFairPoorQuality of ConferenceConference FormatQuality of Lecture MaterialsQuality of Audio/Visual ContentMet Stated ObjectivesWill Alter My Practice PerformanceConvinced Me I'm Doing the Right ThingWill Be Relevant To My PracticeSatisfied My ExpectationsWhich factors are important in your decision to attend a LECOM-sponsored Primary Care Conference?*Very ImportantImportantNeutralSomewhat ImportantNot ImportantContentCostLocationCME Credits OfferedConference DatePatient-Safety RequirementsHow would you rate this program for keeping the content commercial free?*Accredited CME programs must be free of commercial bias for or against any product. ExcellentVery GoodGoodFairPoorDid you have adequate opportunity to receive answers to all of your questions?*YesNoHave you attended a previous LECOM Primary Care Conference?*YesNoIf yes, how many LECOM Primary Care Conferences have you attended?*1234567891010+Do you practice in a Medically Underserved Area?*YesNoDo you practice in a rural area?*YesNoSuggestions for topics or improvements for next year’s conference.Credit Attestation SectionThe information below is required to issue CME credits for attending the conference.Enter your first and last name* First Last Select your suffix.*DOMDPhDPADCNPRNCRNLPNMTPTPTAOTSTSWNHADMDPCHARDNot ListedNot Listed Suffix*If your suffix isn't listed, please enter it below.Email Address*This is the email address where your certificate will be sent. Enter Email Confirm Email AOA Number*If you do not know your AOA number or do not have an AOA number, please enter 000000. Please note, if you are a DO physician, without your AOA number, this could delay submitting your credits to the AOA in a timely manner.Credit Hours*Enter the total number of hours you attended at this conference. Attendees that attended lectures on Thursday thru Sunday can claim up to 25 credit hours. Attendees that only attended Friday thru Sunday can claim up to 20 credit hours.Please enter a number from 1 to 25.Credit Certification*By checking the box, I certify that the amount of credit hours I entered in the box above is correct and accurate.The button to submit your entry will not display until you select the box below. I certify that the information I entered is accurate.PhoneThis field is for validation purposes and should be left unchanged.