EDUCATIONAL ASSESSMENT AND CREDIT FORM (continued)What other practice changes will you make or consider making as a result of this activity?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What additional information or training do you need on the activity topics or other oncologyrelatedtopics?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .As part of our ongoing, continuous quality-improvement effort, we conduct postactivity followupsurveys to assess the impact of our educational interventions on professional practice. Pleaseindicate your willingness to participate in such a survey.Yes, I am willing to participate in a follow-up survey. No, I am not willing to participate in a follow-up survey.PA RT T WO — Please tell us about the moderator and faculty for this educational activity4 = Excellent 3 = Good 2 = Adequate 1 = SuboptimalFaculty Knowledge of subject matter Effectiveness as an educatorHoward A Burris III, MD 4 3 2 1 4 3 2 1John Crown, MD 4 3 2 1 4 3 2 1William J Gradishar, MD 4 3 2 1 4 3 2 1Julie R Gralow, MD 4 3 2 1 4 3 2 1Daniel F Hayes, MD 4 3 2 1 4 3 2 1Eleftherios P Mamounas, MD, MPH 4 3 2 1 4 3 2 1Kathy D Miller, MD 4 3 2 1 4 3 2 1Joyce O’Shaughnessy, MD 4 3 2 1 4 3 2 1Peter M Ravdin, MD, PhD 4 3 2 1 4 3 2 1George W Sledge Jr, MD 4 3 2 1 4 3 2 1Sandra M Swain, MD 4 3 2 1 4 3 2 1Eric P Winer, MD 4 3 2 1 4 3 2 1Moderator Knowledge of subject matter Effectiveness as an educatorNeil Love, MD 4 3 2 1 4 3 2 1Please recommend additional faculty for future activities:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Other comments about the moderator and faculty for this activity:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .REQ UE S T F O R CREDIT — Please print clearlyName: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specialty: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Professional Designation:MD DO PharmD NP RN PA Other. . . . . . . . . . . . . . . . . . . . . . . .Medical License/ME Number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Last 4 Digits of SSN (required): . . . . . . . . . . . . . . . . . . . . . . . . . . .Street Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Box/Suite: . . . . . . . . . . . . . . . . . . . . . .City, State, Zip: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Telephone: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Email: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Research To Practice designates this educational activity for a maximum of 5.25 AMA PRACategory 1 Credits. Physicians should only claim credit commensurate with the extent of theirparticipation in the activity.I certify my actual time spent to complete this educational activity to be _________ hour(s).Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . .SABCS08To obtain a certificate of completion and receive credit for this activity, please complete the Posttest,fill out the Educational Assessment and Credit Form and fax both to (800) 447-4310, ormail both to Research To Practice, One Biscayne Tower, 2 South Biscayne Boulevard, Suite 3600,Miami, FL 33131. You may also complete the Post-test and Educational Assessment online atwww.ResearchToPractice.com/SABCS_ 2008/CME.20
ModeratorManaging EditorScientific DirectorSenior Director, Medical AffairsWritersContinuing Education Administrator for NursingContent ValidationDirector, Creative and Copy EditingCreative ManagerGraphic DesignersSenior Production EditorTraffic ManagerCopy EditorsProduction ManagerAudio ProductionWeb MasterFaculty Relations ManagerCME Director/CPD DirectorContact InformationFor CME/CNE InformationNeil Love, MDKathryn Ault Ziel, PhDRichard Kaderman, PhDAviva Asnis-Alibozek, PA-C, MPASLilliam Sklaver Poltorack, PharmDDouglas PaleySally Bogert, RNC, WHCNPMargaret PengErin WallClayton CampbellJessica McCarrickAura HerrmannFernando RendinaJessica BenitezJason CunniusTamara DabneyClaudia MunozDeepti NathAlexis OnecaTere SosaMargo HarrisDavid HillRosemary HulceKirsten MillerPat Morrissey/HavlinCarol PeschkeSusan PetroneTracy PotterFrank CesaranoJohn RibeiroMelissa VivesIsabelle TateNeil Love, MDResearch To PracticeOne Biscayne Tower2 South Biscayne Boulevard, Suite 3600Miami, FL 33131Fax: (305) 377-9998Email: DrNeilLove@ResearchToPractice.comEmail: CE@ResearchToPractice.comCopyright © 2009 Research To Practice. All rights reserved.The compact discs, Internet content and accompanyingprinted material are protected by copyright. No part of thisprogram may be reproduced or transmitted in any form or byany means, electronic or mechanical, including photocopying,recording or utilizing any information storage and retrievalsystem, without written permission from the copyright owner.The opinions expressed are those of the presenters and arenot to be construed as those of the publisher or grantors.Participants have an implied responsibility to use the newlyacquired information to enhance patient outcomes and theirown professional development. The information presented inthis activity is not meant to serve as a guideline for patientmanagement.Any procedures, medications or other courses of diagnosisor treatment discussed or suggested in this activity shouldnot be used by clinicians without evaluation of their patients’conditions and possible contraindications or dangers in use,review of any applicable manufacturer’s product informationand comparison with recommendations of other authorities.