Peer-to-Peer Dialogue Credit Submission Form

Complete and submit this form to apply for .5 credit hours of 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 all three questions and the activity evaluation form must be completed to receive credit.

* = required fields
Participant information
*First Name:
*Last Name:
*Please indicate your degree(s): MD DO PharmD APRN
PA Other:
*E-mail:
*Address:
 
*City:
*State:
*Zip:
*Phone:
*Fax:
 
 
Evaluation
1. Please rate the effectiveness of this activity.
1 – Very Ineffective   2 –Ineffective   3 –Effective   4 – Very Effective
Ease of use 1 2 3 4
Available references 1 2 3 4
Applicable references 1 2 3 4
Technological ease 1 2 3 4
2. Did the activity meet your learning objectives?
Not at all met Partially met Met Thoroughly met
3. Will you apply the information to change your practice performance?
Yes No Not sure
4. If you have applied information to your patient care, has there been any change in patient health status as a result?
Yes No Not applicable
 
 
 
 

 
 

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