aEEG Bonus Modules

Synapse aEEG Bonus Modules Evaluation:
Thank you for your time. This survey will only take you a FEW minutes to complete. Please note, that each individual requesting a Continuing Education Certificate must complete a separate evaluation form.
Choose Your Module:*
Choose from the list of modules on the dropdown menu below
Evaluate the Presentation Style and Content --*
Gabriel F. T. Variane, MD
Excellent Very Good Good Fair Poor
The instructor’s ability to explain was
The pace of the material presented was
The content was clear and easy to follow
The content was relevant to my daily practice
Evaluate the Presentation Style and Content --*
Kathi Salley Randall RN, MSN, CNS, NNP-BC
Excellent Very Good Good Fair Poor
The instructor’s ability to explain was
The pace of the material presented was
The content was clear and easy to follow
The content was relevant to my daily practice

Evaluation of Learning Objective(s) --*

Rate how well the presentation met the following learning objectives.

	Excellent	Very Good	Good	Fair	Poor
List at least two clinical scenarios when aEEG could be added to the care of NICU infants.
Describe how aEEG changes with increasing gestational age.
Discuss the evidence presented by the speaker related to the use of aEEG in infants with congenital heart disease.

Evaluation of Learning Objective(s) --*

Rate how well the presentation met the following learning objectives.

	Excellent	Very Good	Good	Fair	Poor
Classify the background patterns for sample aEEG tracings.
Identify the presence (or absence) of sleep wake cycling.
Assess the symmetry of sample aEEG tracings.
Identify suspicious areas on the sample aEEG tracings.

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Continuing Education & Certificate Information
Complete the information below to receive a certificate of Participation & Continuing Education. By entering your information below, you certify that you have personally watched all presentations and entered this information after doing so, and that you are submitting this form only for yourself.
Name*
First Last
Job Title/Credentials
Please provide one of the following -- You State License#, Employee#, Last 4 digits of your Social (One of these is required for CE Certificate)*
Email*
Hospital Name
Hospital State
Hospital City
Enter any other comments here. Thank you for your time!
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Module
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Course Code Prefix*

These numbers will show BEFORE the course code on the template.
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Template Color*

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Number of Units Earned*

(Example: 1 hour, 3 hours, 10 magic beans -- be sure to add the measurement)

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	Excellent	Very Good	Good	Fair	Poor
The instructor’s ability to explain was
The pace of the material presented was
The content was clear and easy to follow
The content was relevant to my daily practice

	Excellent	Very Good	Good	Fair	Poor
The instructor’s ability to explain was
The pace of the material presented was
The content was clear and easy to follow
The content was relevant to my daily practice

Synapse aEEG Bonus Modules Evaluation: