New Eval PCOG – ACRM COG

Pediatric COG Evaluation

Name with Credentials *

First

Last

Please add your professional credentials to your last name. Example: Doe, MD

Email *

1. In which practice setting(s) do you provide pediatric cognitive rehabilitation secondary to brain injury? Select all that apply *

Acute Inpatient Rehabilitation
Subacute Inpatient Rehabilitation (specialized brain injury program)
Skilled nursing facility or other long term care
Outpatient
Day Program
Community Based Program
Other (please specify):

2. What percentage of your current practice is committed to pediatric cognitive rehabilitation? Enter a percentage (0–100%) *

3. Please identify your primary specialization? *

4. How long have you worked in this career? Enter number of years *

5. What are your three primary reasons for attending this training?

Reason 1 *

Reason 2 *

Reason 3 *

6. Would you recommend this training to a colleague?

7. Overall, how satisfied are you with this training experience? *

5 Strongly Agree	4 Agree	3 Neutral	2 Disagree	1 Strongly Disagree
5 Strongly AgreeItem #1 5 Strongly Agree	4 AgreeItem #1 4 Agree	3 NeutralItem #1 3 Neutral	2 DisagreeItem #1 2 Disagree	1 Strongly DisagreeItem #1 1 Strongly Disagree

8. Please share your suggestions for how this course might be improved. *

9. Please rate the speaker and the presentation with 5 representing Strongly Agree and 1 representing Strongly Disagree

Module 1: Overview of the Course and Introduction to the Unique Issues of Pediatric Brain Injury Rehabilitation - Racheal Smetana, PsyD - Please state your level of agreement with the following statements: *

	5 Strongly Agree	4 Agree	3 Neutral	2 Disagree	1 Strongly Disagree
The presentation was engaging.	5 Strongly AgreeThe presentation was engaging. 5 Strongly Agree	4 AgreeThe presentation was engaging. 4 Agree	3 NeutralThe presentation was engaging. 3 Neutral	2 DisagreeThe presentation was engaging. 2 Disagree	1 Strongly DisagreeThe presentation was engaging. 1 Strongly Disagree
The information presented was relevant to my profession.	5 Strongly AgreeThe information presented was relevant to my profession. 5 Strongly Agree	4 AgreeThe information presented was relevant to my profession. 4 Agree	3 NeutralThe information presented was relevant to my profession. 3 Neutral	2 DisagreeThe information presented was relevant to my profession. 2 Disagree	1 Strongly DisagreeThe information presented was relevant to my profession. 1 Strongly Disagree
The subject of the presentation was adequately covered.	5 Strongly AgreeThe subject of the presentation was adequately covered. 5 Strongly Agree	4 AgreeThe subject of the presentation was adequately covered. 4 Agree	3 NeutralThe subject of the presentation was adequately covered. 3 Neutral	2 DisagreeThe subject of the presentation was adequately covered. 2 Disagree	1 Strongly DisagreeThe subject of the presentation was adequately covered. 1 Strongly Disagree
The instructor knew the subject matter.	5 Strongly AgreeThe instructor knew the subject matter. 5 Strongly Agree	4 AgreeThe instructor knew the subject matter. 4 Agree	3 NeutralThe instructor knew the subject matter. 3 Neutral	2 DisagreeThe instructor knew the subject matter. 2 Disagree	1 Strongly DisagreeThe instructor knew the subject matter. 1 Strongly Disagree
The instructor presented content effectively.	5 Strongly AgreeThe instructor presented content effectively. 5 Strongly Agree	4 AgreeThe instructor presented content effectively. 4 Agree	3 NeutralThe instructor presented content effectively. 3 Neutral	2 DisagreeThe instructor presented content effectively. 2 Disagree	1 Strongly DisagreeThe instructor presented content effectively. 1 Strongly Disagree

Module 2: Prerequisites for Learning - Attention and Memory - Christine Korterba, PhD, ABPP - Please state your level of agreement with the following statements: *

	5 Strongly Agree	4 Agree	3 Neutral	2 Disagree	1 Strongly Disagree
The presentation was engaging.	5 Strongly AgreeThe presentation was engaging. 5 Strongly Agree	4 AgreeThe presentation was engaging. 4 Agree	3 NeutralThe presentation was engaging. 3 Neutral	2 DisagreeThe presentation was engaging. 2 Disagree	1 Strongly DisagreeThe presentation was engaging. 1 Strongly Disagree
The information presented was relevant to my profession.	5 Strongly AgreeThe information presented was relevant to my profession. 5 Strongly Agree	4 AgreeThe information presented was relevant to my profession. 4 Agree	3 NeutralThe information presented was relevant to my profession. 3 Neutral	2 DisagreeThe information presented was relevant to my profession. 2 Disagree	1 Strongly DisagreeThe information presented was relevant to my profession. 1 Strongly Disagree
The subject of the presentation was adequately covered.	5 Strongly AgreeThe subject of the presentation was adequately covered. 5 Strongly Agree	4 AgreeThe subject of the presentation was adequately covered. 4 Agree	3 NeutralThe subject of the presentation was adequately covered. 3 Neutral	2 DisagreeThe subject of the presentation was adequately covered. 2 Disagree	1 Strongly DisagreeThe subject of the presentation was adequately covered. 1 Strongly Disagree
The instructor knew the subject matter.	5 Strongly AgreeThe instructor knew the subject matter. 5 Strongly Agree	4 AgreeThe instructor knew the subject matter. 4 Agree	3 NeutralThe instructor knew the subject matter. 3 Neutral	2 DisagreeThe instructor knew the subject matter. 2 Disagree	1 Strongly DisagreeThe instructor knew the subject matter. 1 Strongly Disagree
The instructor presented content effectively.	5 Strongly AgreeThe instructor presented content effectively. 5 Strongly Agree	4 AgreeThe instructor presented content effectively. 4 Agree	3 NeutralThe instructor presented content effectively. 3 Neutral	2 DisagreeThe instructor presented content effectively. 2 Disagree	1 Strongly DisagreeThe instructor presented content effectively. 1 Strongly Disagree

Module 3: – Retraining Visual Spatial and Motor Functional Skills - Tanya Brown, PhD, ABPP - Please state your level of agreement with the following statements: *

	5 Strongly Agree	4 Agree	3 Neutral	2 Disagree	1 Strongly Disagree
The presentation was engaging.	5 Strongly AgreeThe presentation was engaging. 5 Strongly Agree	4 AgreeThe presentation was engaging. 4 Agree	3 NeutralThe presentation was engaging. 3 Neutral	2 DisagreeThe presentation was engaging. 2 Disagree	1 Strongly DisagreeThe presentation was engaging. 1 Strongly Disagree
The information presented was relevant to my profession.	5 Strongly AgreeThe information presented was relevant to my profession. 5 Strongly Agree	4 AgreeThe information presented was relevant to my profession. 4 Agree	3 NeutralThe information presented was relevant to my profession. 3 Neutral	2 DisagreeThe information presented was relevant to my profession. 2 Disagree	1 Strongly DisagreeThe information presented was relevant to my profession. 1 Strongly Disagree
The subject of the presentation was adequately covered.	5 Strongly AgreeThe subject of the presentation was adequately covered. 5 Strongly Agree	4 AgreeThe subject of the presentation was adequately covered. 4 Agree	3 NeutralThe subject of the presentation was adequately covered. 3 Neutral	2 DisagreeThe subject of the presentation was adequately covered. 2 Disagree	1 Strongly DisagreeThe subject of the presentation was adequately covered. 1 Strongly Disagree
The instructor knew the subject matter.	5 Strongly AgreeThe instructor knew the subject matter. 5 Strongly Agree	4 AgreeThe instructor knew the subject matter. 4 Agree	3 NeutralThe instructor knew the subject matter. 3 Neutral	2 DisagreeThe instructor knew the subject matter. 2 Disagree	1 Strongly DisagreeThe instructor knew the subject matter. 1 Strongly Disagree
The instructor presented content effectively.	5 Strongly AgreeThe instructor presented content effectively. 5 Strongly Agree	4 AgreeThe instructor presented content effectively. 4 Agree	3 NeutralThe instructor presented content effectively. 3 Neutral	2 DisagreeThe instructor presented content effectively. 2 Disagree	1 Strongly DisagreeThe instructor presented content effectively. 1 Strongly Disagree

Module 4: Social Communication and Behavioral Interventions - Jennifer Lundine, PhD - Please state your level of agreement with the following statements: *

	5 Strongly Agree	4 Agree	3 Neutral	2 Disagree	1 Strongly Disagree
The presentation was engaging.	5 Strongly AgreeThe presentation was engaging. 5 Strongly Agree	4 AgreeThe presentation was engaging. 4 Agree	3 NeutralThe presentation was engaging. 3 Neutral	2 DisagreeThe presentation was engaging. 2 Disagree	1 Strongly DisagreeThe presentation was engaging. 1 Strongly Disagree
The information presented was relevant to my profession.	5 Strongly AgreeThe information presented was relevant to my profession. 5 Strongly Agree	4 AgreeThe information presented was relevant to my profession. 4 Agree	3 NeutralThe information presented was relevant to my profession. 3 Neutral	2 DisagreeThe information presented was relevant to my profession. 2 Disagree	1 Strongly DisagreeThe information presented was relevant to my profession. 1 Strongly Disagree
The subject of the presentation was adequately covered.	5 Strongly AgreeThe subject of the presentation was adequately covered. 5 Strongly Agree	4 AgreeThe subject of the presentation was adequately covered. 4 Agree	3 NeutralThe subject of the presentation was adequately covered. 3 Neutral	2 DisagreeThe subject of the presentation was adequately covered. 2 Disagree	1 Strongly DisagreeThe subject of the presentation was adequately covered. 1 Strongly Disagree
The instructor knew the subject matter.	5 Strongly AgreeThe instructor knew the subject matter. 5 Strongly Agree	4 AgreeThe instructor knew the subject matter. 4 Agree	3 NeutralThe instructor knew the subject matter. 3 Neutral	2 DisagreeThe instructor knew the subject matter. 2 Disagree	1 Strongly DisagreeThe instructor knew the subject matter. 1 Strongly Disagree
The instructor presented content effectively.	5 Strongly AgreeThe instructor presented content effectively. 5 Strongly Agree	4 AgreeThe instructor presented content effectively. 4 Agree	3 NeutralThe instructor presented content effectively. 3 Neutral	2 DisagreeThe instructor presented content effectively. 2 Disagree	1 Strongly DisagreeThe instructor presented content effectively. 1 Strongly Disagree

Module 5: Retraining Executive Functioning: Initiation, Problem Solving/Reasoning, Planning/Organization, Disinhibition/Emotional Regulation - Felicia Connor, PsyD, ABPP - Please state your level of agreement with the following statements: *

	5 Strongly Agree	4 Agree	3 Neutral	2 Disagree	1 Strongly Disagree
The presentation was engaging.	5 Strongly AgreeThe presentation was engaging. 5 Strongly Agree	4 AgreeThe presentation was engaging. 4 Agree	3 NeutralThe presentation was engaging. 3 Neutral	2 DisagreeThe presentation was engaging. 2 Disagree	1 Strongly DisagreeThe presentation was engaging. 1 Strongly Disagree
The information presented was relevant to my profession.	5 Strongly AgreeThe information presented was relevant to my profession. 5 Strongly Agree	4 AgreeThe information presented was relevant to my profession. 4 Agree	3 NeutralThe information presented was relevant to my profession. 3 Neutral	2 DisagreeThe information presented was relevant to my profession. 2 Disagree	1 Strongly DisagreeThe information presented was relevant to my profession. 1 Strongly Disagree
The subject of the presentation was adequately covered.	5 Strongly AgreeThe subject of the presentation was adequately covered. 5 Strongly Agree	4 AgreeThe subject of the presentation was adequately covered. 4 Agree	3 NeutralThe subject of the presentation was adequately covered. 3 Neutral	2 DisagreeThe subject of the presentation was adequately covered. 2 Disagree	1 Strongly DisagreeThe subject of the presentation was adequately covered. 1 Strongly Disagree
The instructor knew the subject matter.	5 Strongly AgreeThe instructor knew the subject matter. 5 Strongly Agree	4 AgreeThe instructor knew the subject matter. 4 Agree	3 NeutralThe instructor knew the subject matter. 3 Neutral	2 DisagreeThe instructor knew the subject matter. 2 Disagree	1 Strongly DisagreeThe instructor knew the subject matter. 1 Strongly Disagree
The instructor presented content effectively.	5 Strongly AgreeThe instructor presented content effectively. 5 Strongly Agree	4 AgreeThe instructor presented content effectively. 4 Agree	3 NeutralThe instructor presented content effectively. 3 Neutral	2 DisagreeThe instructor presented content effectively. 2 Disagree	1 Strongly DisagreeThe instructor presented content effectively. 1 Strongly Disagree

Module 6: Training Families and Teachers to Implement Cognitive Rehab Strategies - Drew Nagele, PsyD, ABPP, FACRM - Please state your level of agreement with the following statements: *

	5 Strongly Agree	4 Agree	3 Neutral	2 Disagree	1 Strongly Disagree
The presentation was engaging.	5 Strongly AgreeThe presentation was engaging. 5 Strongly Agree	4 AgreeThe presentation was engaging. 4 Agree	3 NeutralThe presentation was engaging. 3 Neutral	2 DisagreeThe presentation was engaging. 2 Disagree	1 Strongly DisagreeThe presentation was engaging. 1 Strongly Disagree
The information presented was relevant to my profession.	5 Strongly AgreeThe information presented was relevant to my profession. 5 Strongly Agree	4 AgreeThe information presented was relevant to my profession. 4 Agree	3 NeutralThe information presented was relevant to my profession. 3 Neutral	2 DisagreeThe information presented was relevant to my profession. 2 Disagree	1 Strongly DisagreeThe information presented was relevant to my profession. 1 Strongly Disagree
The subject of the presentation was adequately covered.	5 Strongly AgreeThe subject of the presentation was adequately covered. 5 Strongly Agree	4 AgreeThe subject of the presentation was adequately covered. 4 Agree	3 NeutralThe subject of the presentation was adequately covered. 3 Neutral	2 DisagreeThe subject of the presentation was adequately covered. 2 Disagree	1 Strongly DisagreeThe subject of the presentation was adequately covered. 1 Strongly Disagree
The instructor knew the subject matter.	5 Strongly AgreeThe instructor knew the subject matter. 5 Strongly Agree	4 AgreeThe instructor knew the subject matter. 4 Agree	3 NeutralThe instructor knew the subject matter. 3 Neutral	2 DisagreeThe instructor knew the subject matter. 2 Disagree	1 Strongly DisagreeThe instructor knew the subject matter. 1 Strongly Disagree
The instructor presented content effectively.	5 Strongly AgreeThe instructor presented content effectively. 5 Strongly Agree	4 AgreeThe instructor presented content effectively. 4 Agree	3 NeutralThe instructor presented content effectively. 3 Neutral	2 DisagreeThe instructor presented content effectively. 2 Disagree	1 Strongly DisagreeThe instructor presented content effectively. 1 Strongly Disagree

10. How much did you learn as a result of this CE program? *

5 A great deal	4 Quite a bit	3 A moderate amount	2 A little	1 Very little
5 A great dealThe presentation was engaging. 5 A great deal	4 Quite a bitThe presentation was engaging. 4 Quite a bit	3 A moderate amountThe presentation was engaging. 3 A moderate amount	2 A littleThe presentation was engaging. 2 A little	1 Very littleThe presentation was engaging. 1 Very little

11. How useful was the content of this CE program for your practice or other professional development? *

5 Extremely useful	4 Very useful	3 Moderately useful	2 Slightly useful	1 Not at all useful
5 Extremely usefulThe presentation was engaging. 5 Extremely useful	4 Very usefulThe presentation was engaging. 4 Very useful	3 Moderately usefulThe presentation was engaging. 3 Moderately useful	2 Slightly usefulThe presentation was engaging. 2 Slightly useful	1 Not at all usefulThe presentation was engaging. 1 Not at all useful

12. How useful were the resources offered on the training companion site? *

5 Extremely useful	4 Very useful	3 Moderately useful	2 Slightly useful	1 Not at all useful
5 Extremely usefulThe presentation was engaging. 5 Extremely useful	4 Very usefulThe presentation was engaging. 4 Very useful	3 Moderately usefulThe presentation was engaging. 3 Moderately useful	2 Slightly usefulThe presentation was engaging. 2 Slightly useful	1 Not at all usefulThe presentation was engaging. 1 Not at all useful

14 How will you implement these changes?

Charnge 1 *

Change 2 *

14. How will you implement these changes?

Implementation plan 1 *

Implementation plan 2 *

no, us experience?

15. The content was fair, balanced, and free of commercial bias. *

Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Strongly DisagreeItem #1 Strongly Disagree	DisagreeItem #1 Disagree	NeutralItem #1 Neutral	AgreeItem #1 Agree	Strongly AgreeItem #1 Strongly Agree

16. What type of certificate are you claiming? *

17. Please provide any additional comments (i.e. future programming)