CME PROCESSING REQUEST AND EVALUATION FORM v.1.2

Thank you for choosing Challenger.  Please read and complete the following.

INSTRUCTIONS AND REQUIREMENTS

You are about to submit for CME credit based on the work you have completed in your Challenger program.  By submitting this request, you attest that all work is your own and you have read the CME instructions and requirements in your Challenger product.

BE ADVISED: Only submissions claiming 10 or more credits (except in cases where a given course awards less than 10 credits) will be processed.  Please continue working if you do not have at least 10 credits earned in your coursework and resubmit.

CME certificates are typically processed within five business days following receipt of your submission. A certificate will be mailed to you upon processing completion. Please allow for transit time. All submissions are subject to verification. All assessments with scores of 80% or better will be credited. Credits are rounded down to the nearest quarter-credit. 

As part of the CME fulfillment process outlined by the ACCME, please complete the following User Evaluation as part of your processing request. Upon submission of this completed form, an auto-verification and contact information will be sent to you at the email provided.  All client information is kept confidential.

We are a customer service-oriented company and if there is anything further we can do to fulfill your CME needs, please let us know. Thank you.

COMPLETE THE FOLLOWING

USER INFORMATION (*Required field)

Please enter your preferred Email Address:
(This address will receive transmission confirmation.)

 *required

Please enter your First Name

 *

Please enter your Last Name

 *

What is your Degree

 *

What is your primary Specialty

 *

Please enter your Organization/Institution

Please enter your primary street Address

 *

Please enter your Office/Suite/Apartment #

Please enter your City

 *

Please enter your State or US territory
(Customers outside of the US territories, please select "Other")

 *

Please enter your US Zip or mail code

 *

If outside the U.S, enter your Country

Enter your Challenger Member ID: (e.g.: tfranklin)
(Your Member ID is printed on your product invoice.)

Please enter your primary Phone number:
(e.g. xxx-xxx-xxxx)

Please enter your Fax number:
(e.g. xxx-xxx-xxxx)

REPORT YOUR WORK (*Required field)

In which program did you work? Please select the Course Title from which you are requesting CME:
(As printed on your CD-ROM or listed in your online account)

*

In order to speed processing, please tell us how you used this product to create and send scores.
(Which statement best describes you?)

 Ran program from the CD-ROM and emailed my scores.
 Installed program to my hard-drive and emailed my scores.
 Logged into www.challengercme.com and logged scores online. *

Have you submitted scores from this course previously?

 No, this is my first submission of scores from this course.
 Yes, I have submitted scores from this course previously.

Any special comments for the CME department?
(e.g. "I'm seeking at least 20 credits", etc.)

YOUR FEEDBACK (Tell us about your experience.)

How did you hear about Challenger?
If Other, please explain:

What was your primary reason to purchase this product?

 *
If Other, please explain:

What other programs do you use for this purpose?

How often do your use your Challenger course?

Please rate your overall satisfaction of the product, including price, features, customer support, etc.

Would you purchase additional programs from Challenger?

 Yes
No  If No, please explain:

Would you recommend this Challenger product to someone else?

 Yes
No Please explain:

On a scale of 1-5 (5 being most favorable), please rate the product on each of the these features:

 CME Resource
Clinical Reference
Exam Preparation
Educational Material

Was the presentation of material clear and concise?

 Yes
No

Relative to other CME, the educational quality of this program was:

To what extent has this program fulfilled the objective of imparting the knowledge appropriate for an experienced clinician in the areas you studied?

How much has this CME activity enhanced your clinical competence, confidence and effectiveness?

For what other specific topics/skills would you like new CE programs?

Which of these attributes has your use of this program improved? (select all that apply)

 Knowledge | Skills | Attitudes

Was this program a cost effective way to earn CME credit?

 Yes
No

What feature(s) would you most like to see added to this program?

What feature(s) of the program do you like most or use most often?

In your opinion, what are this program's major shortcomings?

Describe any problems or suggestions regarding our software or customer service:

Did you feel there was a bias toward any particular product or company?

 No
Yes -- If yes, please explain:

What is your current medical status?

Rate your level of knowledge of the topic covered BEFORE using this product.

Rate your level of knowledge of the topic covered AFTER using this product.

To what extent has this program promoted improved quality of patient care?

For the following five items, please rate this educational activity Excellent Good Average Fair Poor

a. Extent to which the objectives of this educational activity were met.

 5 4 3 2 1

b. Extent to which you are satisfied with the overall quality of this educational activity.

 5 4 3 2 1

c. To what extent did the activity present scientifically rigorous and balanced information?

 5 4 3 2 1

d. To what extent was the content free of commercial bias in its presentation?

 5 4 3 2 1

e. Rate the likelihood you will make a change in practice behavior based on your participation in this activity.

 5 4 3 2 1