2009 Interactive Case Studies - Case #4 Credit Submission Form

Complete and submit this form to apply for AMA PRA Category 1 Credit™. Upon acceptance of this activity by The France Foundation, you will receive a certificate documenting your successful completion of this activity. Please note that this entire form must be completed to receive credit.

* = required fields
Participant Information:
*First Name: *Last Name:
*Please indicate your degree(s): MD/DO PharmD/RPh APRN PA Other:
*Address: Address 2:
*City: *State: *ZIP:
*Phone: *E-mail:
*Clinician type: Pulmonologist Pathologist Radiologist Primary Care Physician Other:
*Number of years in practice: ≤ 5 6-10 11-15 16-20 21-25 ≥ 25
*What percent of your patients have IPF?
*May we contact you in the future with a brief survey to assess how you have used the information presented in this activity or to assess other educational needs? Yes No

*Indicate the number of AMA PRA Category 1 Credits™ you are claiming (May not exceed 1 credit)
Met Learning Objective:
4 – Strongly Agree   3 – Agree   2 – Disagree   1 – Strongly Disagree
Upon completion of this activity, I will be able to:
Identify common clinical and radiologic features associated with the representative interstitial lung disease case presented herein which will enhance multidisciplinary collaboration 4 3 2 1
Enduring Material:
Please rate the overall content in this activity: Too Basic Appropriate Too Complex
Bias, Fair Balance:
Was this activity fair, balanced, objective, and free from commercial bias? Yes No
If no, please state reason(s):
Practical Application:
4 – Strongly Agree   3 – Agree   2 – Disagree   1 – Strongly Disagree
I felt that the format used in this activity was a beneficial method of learning 4 3 2 1
This case provided clinically relevant information 4 3 2 1
What I learned in this activity will improve my ability to care for my patients with IPF 4 3 2 1
List one thing you would do differently or incorporate into your clinical practice as a result of this educational activity.
Barriers:
What are the top 3 barriers you feel might inhibit your ability to incorporate any of the above changes into your clinical practice?
Ongoing Unmet Educational Needs:
Recommendations for future CME topics in this disease area:
How Did You Come to Participate in this CME Activity?
Direct Mail Colleague Web Search Conference Display E-mail Advertisement
Have You Participated in a PILOT™ CME Activity in the Past? Yes No
If yes, what is the approximate number of PILOT™ CME activities that you have participated in this calendar year?
1-3 4-6 7-9 ≥ 10
If no, after participating in this activity, how likely are you to participate in a PILOT™ CME activity in the future?
Very Likely Likely Unlikely Unsure