Online Program Evaluation Form

Please take a few moments to answer the following questions. When you have answered all questions, press the "submit" button at the bottom of the form and your answers will be sent to the project team. Your evaluation will be anonymous.

Questions

1. What is your profession?
   
   
2. Highest degree completed or Degree program currently attending?
   
3. At what stage is your career?
   Please choose... Training Complete Fellowship Resident Intern / Extern Attending Degree Program Other
4. What is your therapeutic area of practice?
   Please choose... Family Practice Internal Medicine OB/GYN Pediatrics Other
5. Number of years in practice?
   
   
   Questions 6-9: Did the material presented meet the following educational objectives?
   
   
6. Increased your awareness of the psychological and social implications of genetic testing?
   Yes No
7. Increased your understanding of the accuracy, reliability and implications of genetic testing in general?
   Yes No
8. Increased your understanding of the accuracy, reliability and implications of genetic testing for breast/ovarian cancer, cystic fibrosis and familial adenomatous polyposis?
   Yes No
9. Increased your understanding of the concept of an expanded informed consent process for genetic testing?
   Yes No
10. How would you rate this program on its relevance to your clinical practice?
    Excellent
    Good
    Fair
    Poor
11. Rate the program in terms of its ability to hold your interest.
    Excellent
    Good
    Fair
    Poor
12. Was the material presented in a clear and understandable fashion?
    Excellent
    Good
    Fair
    Poor
    
13. How often have you initiated a conversation about genetic testing with a patient?
    Never
    About once a year
    Once a month
    Once a week
    More often than once a week
14. How often have you received requests or inquiries about genetic testing from a patient?
    Never
    About once a year
    Once a month
    Once a week
    More often than once a week
15. How often have you ordered genetic tests?
    Never
    About once a year
    Once a month
    Once a week
    More often than once a week
16. How often have you referred a patient for genetic counseling?
    Never
    About once a year
    Once a month
    Once a week
    More often than once a week
17. How often do you personally counsel patients about genetic testing?
    Never
    About once a year
    Once a month
    Once a week
    More often than once a week
18. After viewing this video, will you be better prepared to counsel patients and their families about genetic testing?
    Definitely
    Possibly
    Unlikely
    Definitely not
19. Are you likely to change your practice in any of the following areas after viewing this program? (Yes or No)
    

    A.	More likely to seek out information about genetic testing?	Yes No
    B.	More likely to initiate counseling of your patients about genetic testing?	Yes No
    C.	More likely to refer patients to genetic counseling?	Yes No
    D.	More likely to expand the informed consent process for genetic testing?	Yes No
    E.	More likely to consider the effects of genetic testing on children and adolescents	Yes No
    F.	More likely to emphasize with patients the privacy and confidentiality issues related to genetic testing?	Yes No

20. Overall, how would you rate this video?
    Excellent
    Good
    Fair
    Poor
21. Would you recommend this video to a colleague?
    Definitely
    Possibly
    Unlikely
    Definitely not
22. The most valuable part of this videotape was …
    [Enter your answer here]
23. The least valuable part of this videotape was …
    [Enter your answer here]
24. Was the program presented objectively?
    [Enter your answer here]