Continuing Education Evaluation Form - Fill out to get CE ...
Pharmacists Continuing Education Evaluation Form
Fill out for ACPE Approved Statements of Credit
New Mexico Pharmacists Association
2716 San Pedro NE, Suite C, Albuquerque, New Mexico 87110
(505) 265-8729 / (800) 464-8729
“Understanding the Tuberculin Skin Test: A Primer for Non-TB Staff”
ACPE# 0104-9999-17-052-H04-P 1.0 Contact Hour or 0.1 CEU Initial Release Date : 8/15/17
Expiration Date: 8/15/20
Pre-Requisite: Introductory webinar at
ACPE CREDIT & CERTIFICATION: Upon completion of the webinar, pharmacists requesting 1.0 contact hour of ACPE credit
will be required to download and complete the program evaluation and forward to NMPhA.
Diana Fortune, RN, BSN
New Mexico Department of Health - Acting TB/RH Program Manager - TB Nurse Consultant, Santa Fe, NM
Did presenter appropriately cover the knowledge-based program objectives below: Please rate using the following scale:
1-Poor 2-Fair 3-Good 4-Excellent
( Describe the cause, transmission and pathogenesis of tuberculosis (TB),
specifically latent tuberculosis infection (LTBI) and its progression to TB disease 1 2 3 4
( Discuss significant recent trends in the epidemiology of TB and identify populations in the
United States and regionally at high-risk of LTBI and progression to TB disease 1 2 3 4
( Identify the limitations inherent in the Mantoux tuberculin skin test (TST) and its use in
administrative TB testing in the pharmacy or other non-public health settings 1 2 3 4
( List the components of a targeted TST health history/risk assessment and their
significance in interpreting TST reactions 1 2 3 4
( Identify patients who would benefit from referral for further medical evaluation and describe
the appropriate referral process 1 2 3 4
Please rate the presenter and program using the following scale: 1-Poor 2-Fair 3-Good 4-Excellent
The program and speaker was free from commercialism and bias. (If not a 4, please note in comments below) 1 2 3 4
The presenter demonstrated expertise in the topic. 1 2 3 4
The program met the advertised objectives. 1 2 3 4
The information provided will be useful in my practice. 1 2 3 4
The content was interesting & added to my knowledge. 1 2 3 4
The web-based materials were useful. . 1 2 3 4
The active learning strategies (questions, cases, discussion) were appropriate & effective. 1 2 3 4
I would like further speakers on this topic. 1 2 3 4
Additional Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________
Name: (Print Clearly) ____________________________________ Profession: (R.Ph., CPhT, etc.)__________
NABP e-Profile ID:_________________DOB (MMDD)___________ Employer :________________________
( to obtain ID #)
Address: __________________________________________________________________________________
(you wish listed in the NMPhA Database)
City: _____________________________________________________ State: _____ Zip: _________________
Signature: ______________________________________________________________ Date: _____________
(I certify that I attended the above program in its entirety for the continuing education contact hour(s) indicated.)
Phone: __________________ Fax: __________________ E-Mail: ____________________________________
Participants are required to turn in a completed program evaluation form to receive the designated CEUs. Your CPE credits will be submitted into the CPE Monitor Database within 60 days based on the information provided on this form.
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