Form 1 survey

1. CME and physician practice. OMB#0925-XXXX, Exp: XX-XXXX
Burden Disclosure Statement: Public reporting burden for this collection of information is estimated to
average 1 minute per survey, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a
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regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda,
MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.
Please complete this voluntary survey. We welcome your feedback and appreciate your honesty.
Thank you for attending the (insert name of conference). As part of the onsite evaluation process, you
provided us this email to help us determine the usefulness and outcomes of the education that was
provided.
To refresh your memory, (insert the title of the conference)
As we strive to improve our ability to deliver information at NIH that has a positive impact on your
practice, patient care, and/or research, we ask that you complete this brief voluntary electronic survey
below.

1. Did the options, alternatives, or information that were provided in the
(insert name of conference) have an impact on your approach to research
or patient care?
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Yes

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No

If yes, please elaborate:

2. Did the presentation initiate or increase collaboration between your
efforts and the eforts of other investigators in your field of research?
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Yes

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No

If yes, please elaborate:

3. To what degree do you think that your practice or research focus has
been changed as a result of the activity?