Pain Management

#5E014WEB

CME ANSWER SHEET

This Answer Sheet Expires January, 2008
First Edition, First Printing

Palliative Care:
Hospice, Palliative Care for Children
Ethical Issues in Palliative Care, Legal Issues in Palliative Care

Please fill in the space that corresponds to your answer for each question. When you have completed this answer sheet, please mail or fax it and the completed evaluation form to TIV, Inc. for processing at the address listed below. Your CME certificate will be mailed to you. If you prefer, you may submit the answer sheet and evaluation form via the internet at www.tivcme.com/pmpc3 and print your CME certificate immediately. You need a score of at least 70% and a completed course evaluation to receive credit. You will be notified promptly if you need to retake the test, and a new answer sheet will be
forwarded to you. Please retain a copy of the test for your files.

Mail to:

TIV, Inc.
124 West Monroe
Saint Louis, MO 63122
800-473-0138

Fax to:

TIV, Inc.
866-965-8999

You will receive a certificate of completion within 7-10 days after receipt of your test and evaluation form; and, in the event you fail, you will be notified regarding a retake examination on the same concepts.

RUSH Processing: Rush processing is available and requires an additional $25 processing fee. You must fax your test and evaluation form to TIV, Inc. at 866-965-8999, and include your credit card information on the form. Your request will be processed and a certificate will be faxed to you within two business days after receipt of your test, pending pass/fail results. Mail requests do not qualify for rush processing.

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CME Evaluation Form This Evaluation Form Expires January, 2008 First Edition, First Printing
Palliative Care: Hospice, Palliative Care for Children Ethical Issues in Palliative Care, Legal Issues in Palliative Care

Please evaluate the course as follows:
a. Excellent	b. Above Average	c. Average	d. Below Average	e. Poor

1. The overall quality of the entire course.
a	b	c	d	e

2. The extent to which this program met the stated objectives.
Describe the services provided by hospice.
a	b	c	d	e
Relate the necessary elements required for a palliative care team.
a	b	c	d	e
Recognize the difficult legal and ethical issues that can arise in end-of-life decisions.
a	b	c	d	e
Implement procedures for improving the quality of care for patients at the end of their lives.
a	b	c	d	e
3. The course was well organized.
a	b	c	d	e

4. The information is presented at the appropriate level.
a	b	c	d	e

5. The topics covered in this course will be helpful in my day-to-day practice.
a	b	c	d	e

6. I did not perceive any undue commercial bias in this course.
Agree	Disagree

7. The program was free from the discussion of experimental or off-label therapies that were not previously disclosed.
Agree	Disagree

8. There was disclosure of the faculty and planning committee members’ relationship with commercial supporters.
Agree	Disagree

9. What was the most helpful part of this course?

10. What was the least helpful part of this course?

11. Do you have any suggestions for future continuing education topics?


SSN:		_________________________________
Name:		_________________________________
Degree:		_________________________________
Title:		_________________________________
Specialty:		_________________________________
Address:		_________________________________
City:		_________________________________
State:		__________
Zip:		__________
Telephone:		_________________________________
Fax:		_________________________________
E-mail:		_________________________________
Comments:		_________________________________
		_________________________________

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the University of Oklahoma College of Medicine and TIV, Inc. The University of Oklahoma College of Medicine is accredited by the ACCME to provide Continuing Medical Education for Physicians. The University of Oklahoma College of Medicine designates this educational activity for a maximum of 4 category 1 credits towards the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity. This program is eligible for application for CME credits under category 2B of the American Osteopathic Association’s CME program.


The charge for this course is $123.00. You can include a check made payable to TIV, Inc. or fill out your credit card information below.

Credit Card Information

Card Type: (Please Circle One)		American Express MasterCard Visa
Card Number:		_________________________________
Expiration Date:		_________________________________
Signature:		_________________________________

Please mail your completed answer sheet and course evaluation along with check for $123
made payable to TIV, Inc. to:

TIV, Inc.
124 W. Monroe
St. Louis, MO 63122
Telephone 314-965-8999
Fax 314-965-6608