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ITPeducation.com™ CME-Webinar - Attestation/Evaluation Form

Quality of Life Instruments in Risk/Benefit Analysis of Therapeutic Options

Complete and submit this form to apply for up to 0.5 AMA PRA Category 1 Credit™. Upon acceptance of this form 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.

Participant Information:

1. First Name:*
2. Last Name:*
3. Please Indicate Your Degree(s):*
     MD/DO PharmD/RPh NP
   RN PA Other:
4. Address:*
5. City:*
6. State/Province:*
7. ZIP/Postal Code:*
8. Email address:*
9. Clinician Type:*
    
     Hematologist Oncologist
   Hepatologist Primary Care Physician
   Other
10. If Other:
11. Number of years in practice:*
      ≤ 5 6-10 11-15
    16-20 21-25 > 25
12. What percent of your patients are at risk for ITP?:*
13. Indicate the number of Credits you are claiming:
    (May not exceed 0.5 credit)*

Bias, Fair Balance:

1. Was this activity fair, balanced, objective,
   and free from commercial bias? Yes No
2. If no, please state reason(s)

Practical Application:

1. 4-Strongly Agree 3-Agree 2-Disagree 1-Strongly Disagree
2. I felt the format used in this activity was a beneficial method of learning. 4 3 2 1
3. This activity provided clinically relevant information. 4 3 2 1
4. What I learned in this activity will improve my ability to care for my patients with ITP. 4 3 2 1
5. List one thing you would do differently or incorporate into you clinical practice as a result of this educational activity:

Barriers:

1. What are the top 3 barriers you feel might inhibit your ability to incorporate any of the above changes into your clinical practice?

Met Learning Objectives:

1. 4-Strongly Agree 3-Agree 2-Disagree 1-Strongly Disagree
2. Upon completion of this activity, I will be able to:
3. Discuss recent findings on patient-assessed quality of life measures in ITP and how these issues may affect risk/benefit analyses and therapeutic management decisions in these patients 4 3 2 1

How Did You Come to Participate in this CME Activity?

1. Colleague Web Search E-mail Advertisement

ITPeducation.com^™ CME Activity Participation

1. Prior to this activity, what is the approximate number of ITPeducation.com^™ CME activities that you have participated in this calendar year? 0 1-3 4-6
   7-9 > 10
2. After participating in this activity, how likely are you to participate in an ITPeducation.com^™ CME activity in the future? Very Likely Likely
   Unlikely Unsure