Idiopathic Pulmonary Fibrosis - Idiopathic Pulmonary Fibrosis Education - IPF Diagnosis

IPF Expert Roundtable Discussion Credit Submission Form

Complete and submit this form to apply for 0.5 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 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

*Percent of patients with IPF in your practice:

*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 0.5 credit)

Met Learning Objectives:
4 – Strongly Agree 3 – Agree 2 – Disagree 1 – Strongly Disagree
Upon completion of this activity, I will be able to:
Describe recent progress in diagnosing IPF comorbid conditions, including pulmonary arterial hypertension (PAH)	4 3 2 1
Describe recent clinical trial results on IPF therapies and incorporate this information into the management	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
What I learned in this activity will improve my ability to care for my patients with IPF	4 3 2 1

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