13 www.metdental.com Evaluation - Managing the Patient with a Worn Dentition 4th Edition Providing dentists with the opportunity for continuing dental education is an essential part of MetLife’s commitment to helping dentists improve the oral health of their patients through education. You can help in this effort by providing feedback regarding the continuing education offering you have just completed. FOR OFFICE USE ONLY Registration/Certification Information (Necessary for proper certification) Name (Last, First, Middle Initial): __________________________________________________________________ Street Address: _____________________________________________________ Suite/Apt. Number _________ City: ______________________________________ State: _______________ Zip: _____________________ Telephone: _______________________________________ Fax: ______________________________________ Date of Birth: ______________________________________ Email: ____________________________________ State(s) of Licensure: _______________________________ License Number(s): __________________________ Preferred Dentist Program ID Number: _____________________________ Check Box If Not A PDP Member AGD Mastership: Yes No AGD Fellowship: Yes No Date: ______________ Please Check One: General Practitioner Specialist Dental Hygienist Other PLEASE PRINT CLEARLY Please respond to the statements below by checking the appropriate box, 1 = POOR 5 = Excellent using the scale on the right. 1 2 3 4 5 1. How well did this course meet its stated educational objectives? 2. How would you rate the quality of the content? 3. Please rate the effectiveness of the author. 4. Please rate the written materials and visual aids used. 5. The use of evidence-based dentistry on the topic when applicable. N/A 6. How relevant was the course material to your practice? 7. The extent to which the course enhanced your current knowledge or skill? 8. The level to which your personal objectives were satisfied. 9. Please rate the administrative arrangements for this course. 10. How likely are you to recommend MetLife’s CE program to a friend or colleague? (please circle one number below:) 10 9 8 7 6 5 4 3 2 1 0 extremely likely neutral not likely at all What is the primary reason for your 0-10 recommendation rating above? 11. Please identify future topics that you would like to see: Thank you for your time and feedback. To complete the program traditionally, please mail your post test and registration/evaluation form to: MetLife Dental Quality Initiatives Program l 501 US Highway 22 l Bridgewater, NJ 08807