How many years have you worked in your respective profession? *

(Use whole numbers)

Please indicate the type(s) of environments in which you currently work: *

Inpatient Acute

Inpatient Rehabilitation Facility

School District/Pediatrics

Home Care Birth-to-Three

Home Care Adult

Outpatient Orthopedics

Outpatient Neurological Setting

Other, please state:

Please indicate the type(s) of environments in which you currently work: Other, please state:

When did you complete the Interprofessional Ethics Course? *

3 months ago

4-6 months ago

7+ months ago

Now that some time has passed since you completed the Interprofessional Ethics Course, we would like to ask again how well the course prepared you to do each of the following: *

	Not at all	A little	Somewhat	Very	Extremely
Work with individuals of other professions to maintain a climate of mutual respect and shared values.	Work with individuals of other professions to maintain a climate of mutual respect and shared values. - Not at all	Work with individuals of other professions to maintain a climate of mutual respect and shared values. - A little	Work with individuals of other professions to maintain a climate of mutual respect and shared values. - Somewhat	Work with individuals of other professions to maintain a climate of mutual respect and shared values. - Very	Work with individuals of other professions to maintain a climate of mutual respect and shared values. - Extremely
Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations.	Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. - Not at all	Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. - A little	Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. - Somewhat	Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. - Very	Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. - Extremely
Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.	Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. - Not at all	Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. - A little	Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. - Somewhat	Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. - Very	Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. - Extremely
Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.	Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. - Not at all	Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. - A little	Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. - Somewhat	Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. - Very	Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. - Extremely

How helpful did you find each of the following aspects of the course? *

	Not at all	A little	Somewhat	Very	Extremely
Online format	Online format - Not at all	Online format - A little	Online format - Somewhat	Online format - Very	Online format - Extremely
Case scenarios	Case scenarios - Not at all	Case scenarios - A little	Case scenarios - Somewhat	Case scenarios - Very	Case scenarios - Extremely
Knowledge checks	Knowledge checks - Not at all	Knowledge checks - A little	Knowledge checks - Somewhat	Knowledge checks - Very	Knowledge checks - Extremely
Available resources	Available resources - Not at all	Available resources - A little	Available resources - Somewhat	Available resources - Very	Available resources - Extremely

Would you recommend this course to a colleague? *

Yes

No

What specific changes did/will you make in your clinical practice as a result of participation in the course? *

What barriers to implementation of the changes listed above did you experience/do you anticipate? *

Additional comments and suggestions for course improvement: *

Leave this field blank