Sample Program Evaluation Form
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1
2Clinical and Laboratory Standards
Institute (CLSI)
940 West Valley Road, Suite 1400
Wayne, PA 19087
Phone 610-688-0100
Program Evaluation
Fax
610-688-0700
Web
Program/Session Title:
Patient Identification and Transfusion Safety: Six years of Experience with Bar Code Scanning
Program Date: March 24, 2011 Program Number: 213-003-11
PLEASE e-mail this completed evaluation to
or print it out and fax it to 610-688-0700.
You will receive your PACE certificate within one week.
Use this form to evaluate the above-titled program/session ONLY. Fill in the numbered circle to indicate your
ratings of this program, objectives, and speaker, using one response per line, completely erasing errors.
SPEAKER RATING John Kemp, M.D.
Low/Poor
High/Excellent
Not Applicable
To what extent:
Was the speaker knowledgeable, organized and effective
N/A
during the presentation?
Did the speaker clarify and focus on the stated objectives?
N/A
Were the speaker's teaching methods & aids effective?
N/A
Were the teaching methods & aids appropriate & effectively
N/A
used?
Low/Poor
High/Excellent
Not Applicable
SPEAKER RATING
David P Papworth, MB FRCPC
To what extent:
Was the speaker knowledgeable, organized and effective
N/A
during the presentation?
Did the speaker clarify and focus on the stated objectives?
N/A
Were the speaker's teaching methods & aids effective?
N/A
Were the teaching methods & aids appropriate & effectively
N/A
used?
Anne M. Smith, MSN, RN
Low/Poor
High/Excellent
Not Applicable
SPEAKER RATING
To what extent:
Was the speaker knowledgeable, organized and effective
N/A
during the presentation?
Did the speaker clarify and focus on the stated objectives?
N/A
Were the speaker's teaching methods & aids effective?
N/A
Were the teaching methods & aids appropriate & effectively
N/A
used?
OBJECTIVES RATING
Low/Poor
High/Excellent
Not Applicable
To what extent was each objective achieved?
Understand the key steps involved in start to finish barcode tracking
N/A
of identification information in the transfusion process.
Understand the potential gains in patient safety that can be achieved
N/A
with barcode technology
Understand how hospital-wide barcode scanning can be effectively
N/A
implemented and continuously maintained through effective
collaboration with Anesthesia and Nursing.
Understand how barcode technology may evolve in the near future
N/A
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