Evaluation Form

    Your name

    Your email

    Which of the following best describes your primary practice setting?

    Please specify

    How long have you been in practice?

    Approximately how many patients do you see each week?

    What percentage of your patients do you currently screen for all 10 ACEs?

    Please select the extent to which you agree/disagree that the activity supported the achievement of its learning objectives?

    Define Adverse Childhood Experiences (ACEs), their prevalence, and their impacts on health, including underlying biological mechanisms.

    Please select the extent to which you agree/disagree that the activity achieved the following:

    The activity enhanced my current knowledge base.

    The educational material provided useful information for my practice.

    The content was evidence-based.

    The cases were effective in presenting the material.

    Based upon your participation in this activity, do you intend to change your practice behavior?

    If you plan to change your practice behavior, what type of changes do you plan to implement? (check all that apply)
    Routine screening for ACEs in childrenRoutine screening for ACEs in adultsApplying the ACEs and Toxic Stress Risk Assessment Algorithm to guide patient careChange in treatment or management approach, based on ACEs score and toxic stress risk assessmentChange in current practice for referrals or linkages to treatment and support servicesChange in interprofessional team communication or collaboration, within team in primary clinical settingChange in interprofessional communication or collaboration, for referrals and off-site partnersOther

    Please specify:

    How confident are you that you will be able to make your intended changes?

    Which of the following do you anticipate will be the primary barrier to implementing these changes?
    Insurance/financial issuesAbility to refer to appropriate services and treatmentsTime constraintsInsufficient interprofessional team support within primary clinical settingSystem constraintsTreatment-related adverse eventsPatient adherence/complianceOther

    Please specify:

    Was the content of this activity fair, balanced, objective, and free of bias?
    YesNo 

    Please explain why:

    Please list any clinical issues/problems within your scope of practice you would like to see addressed in future educational activities, that were not addressed here:

    Please include any other feedback you have on this educational experience:

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