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Print this page: Go to the "File" menu of the window in which this appears and click "print".  Use this one form for all of your course evaluations, do not send in a separate form for each course.

 

Instructions: You must complete an evaluation for each Module that you want credit for.  Respond to statements 1 through 6 on a scale from 1 to 6, with 1 = not applicable,  2 = strongly disagree, 3 = disagree, 4 = neutral, 5 = agree, 6 = strongly agree.  Send in this page with your ANSWER FORM and your fee payment. 


 

Statement 1:  Overall, I was satisfied with this course.

Statement 2:  This course was taught at a level right for me.

Statement 3:  The graphics facilitated my understanding of this course.

Statement 4:  Presentation was organized.

Statement 5:  Presentation met the learning objectives.

Statement 6:  I would recommend this course to a colleague.

 

Circle the Module (Mod) number(s) in the left column for the Modules that you completed.  Mark the squares on the grid  to record your responses.  Answer the questions that follow the grid.  See payment calculation below.

 

Mod

- Statement 1+

- Statement 2 + - Statement 3 + - Statement 4 + - Statement 5 + - Statement 6 +
1 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
2 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
3 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
4 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
5 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
7 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
8 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
10 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
11 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
12 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
13 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
14 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
15 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
16 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
17 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
18 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
19 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
20 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
21 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
22 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
23 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
24 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
25 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
26 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
27 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
28 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
29 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
30 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
31 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
32 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
33 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
34 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
35 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
36 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
37 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
38 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
39 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
41 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
42 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
43 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
44 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
45 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
46 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
47 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
48 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
49 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
50 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
51 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
52 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
53 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
54 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
55 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6

 

B. This course was delivered using the following medium:   Internet  or  CD-ROM

C. How long have you been employed in the field of ophthalmology?  ______________

D. What part of the program was most useful to you?  __________________________

E. What part of the program was least useful to you?  __________________________

F. General comments about the program (use the back of this page if needed):


PAYMENT CALCULATION

 

CEC has changed the way that CE credits are calculated.  Not all eyetec Modules are worth 1 CEC.  Some are now

worth .75 CEC, as indicated on the table below.  Use this table to calculate your payment.

 

Module CE credits Cost Total due:

Mod. 1: Basic A-scan Biometry

.75 CEC, 0 OPS $8.50  

Mod. 2: Advanced A-scan Biometry

1 CEC, 0 OPS $11.00  

Mod. 3: Refractometry Techniques

.75 CEC, 0 OPS $8.50  

Mod. 4: Accommodation and Near Vision

.75 CEC. 0 OPS

$8.50  

Mod. 5: Ocular Motility - Cover Tests

.75 CEC. 0 OPS

$8.50  

Mod. 6: Retinoscopy in Minus Cylinder

1 CEC, 0 OPS

$11.00  

Mod. 7: Retinoscopy in Plus Cylinder

1 CEC, 0 OPS

$11.00  

Mod. 8: General Medical Knowledge, Part 1

.75 CEC. 1 OPS

$8.50  
Mod. 9: General Medical Knowledge, Part 2

.75 CEC. 1 OPS

$8.50

 

Mod. 10: Fundus Photography

1 CEC, 1 OPS

$11.00

 

Mod. 11: Visual Pathways and VF Defects

1 CEC, 0 OPS

$11.00

 

Mod. 12: Visual Field Testing     

1 CEC, 0 OPS

$11.00

 

Mod. 13: Visual Fields, Auto, Monitoring

1 CEC, 0 OPS

$11.00

 

Mod. 14: Visual Fields, Automated, Printout

1 CEC, 0 OPS

$11.00

 

Mod. 15: Visual Fields, Advanced Concepts

1 CEC, 0 OPS

$11.00

 

Mod. 16: Optics: Phys., Geom. and Physio.

1 CEC, 0 OPS

$11.00

 

Mod. 17: Clinical Optics, Part 1

1 CEC, 0 OPS

$11.00

 

Mod. 18: Clinical Optics, Part 2

1 CEC, 0 OPS

$11.00

 

Mod. 19: Clinical Optics, Part 3

1 CEC, 0 OPS

$11.00

 

Mod. 20: Handling Glasses Complaints

1 CEC, 0 OPS

$11.00

 

Mod. 21: Basics of Photography, Part 1

1 CEC, 1 OPS

$11.00

 

Mod. 22: Basics of Photography, Part 2

1 CEC, 1 OPS

$11.00

 

Mod. 23: The Posterior Segment, Part 1

1 CEC, 1 OPS

$11.00

 

Mod. 24: The Posterior Segment, Part 2

1 CEC, 1 OPS

$11.00

 

Mod. 25: Fluorescein Angiography, Part 1

1 CEC, 1 OPS

$11.00

 

Mod. 26: Fluorescein Angiography, Part 2

1 CEC, 1 OPS

$11.00

 

Mod. 27: Extraocular Muscle Anat.and Phys.

1 CEC, 1 OPS

$11.00

 

Mod. 28: Binocular Vision 

1 CEC, 1 OPS

$11.00

 

Mod. 29: EOM Related Skills 

1 CEC, 0 OPS

$11.00

 

Mod. 30: More EOM Related Skills 

.75 CEC, 0 OPS

$8.50

 

Mod. 31: Measuring Prism in Glasses  

1 CEC, 0 OPS

$11.00

 

Mod. 32: Soft Contact Lenses, Part 1      

.5 CEC, 0 OPS

$6.00

 

Mod. 33: Soft Contact Lenses, Part 2      

.5 CEC, 0 OPS

$6.00

 

Mod. 34: Soft Contact Lenses, Part 3      

.5 CEC, 0 OPS

$6.00

 

Mod. 35: Hard Contact Lenses (RGP), Part 1      

1 CEC, 0 OPS

$11.00

 

Mod. 36: Hard Contact Lenses (RGP), Part 2      

1 CEC, 0 OPS

$11.00

 

Mod. 37: Optical Coherence Tomog, Part 1      

1 CEC, 1 OPS

$11.00

 

Mod. 38: Optical Coherence Tomog, Part 2      

1 CEC, 1 OPS

$11.00

 

Mod. 39: History Taking   

1 CEC, 0 OPS

$11.00

 

Mod. 41: Glaucoma, Part 1  

1 CEC, 0 OPS

$11.00

 

Mod. 42: Glaucoma, Part 2  

1 CEC, 0 OPS

$11.00

 

Mod. 43: Anterior Seg., Part 1

1 CEC, 1 OPS

$11.00

 

Mod. 44: Anterior Seg., Part 2

1 CEC, 1 OPS

$11.00

 

Mod. 45: Anterior Seg., Part 3

1 CEC, 1 OPS

$11.00

 

Mod. 46: Refractometry, Basic

1 CEC, 0 OPS

$11.00

 

Mod. 47: More on Refractometry 

1 CEC, 0 OPS

$11.00

 

Mod. 48: Spectral Domain OCT

1.5 CEC, 1 OPS

$16.00

 

Mod. 49: The Orbits

1 CEC, 1 OPS

$11.00

 

Mod. 50: The External Eye, Part 1

1 CEC, 1 OPS

$11.00

 

Mod. 51: The External Eye, Part 2

1 CEC, 1 OPS

$11.00

 

Mod. 52: Slit Lamp

1 CEC, 1 OPS

$11.00

 

Mod. 53: B-scan Basics

1 CEC, .5 OPS

$11.00

 

Mod. 54: B-scan Exam, Part 1

1 CEC, .5 OPS

$11.00

 

Mod. 55: B-scan Exam, Part 2

1 CEC, .5 OPS

$11.00

 

Mod. 53: B-scan Basics

.5 OPS only

$6.50

 

Mod. 54: B-scan Exam, Part 1

.5 OPS only

$6.50

 

Mod. 55: B-scan Exam, Part 2

.5 OPS only

$6.50

 

Grand Total:

 

Send a check or money order (payable to TZV Publishing) with this sheet and the post-test answer form(s) to the address below.  Do not send mail that requires a signature.

 

TZV Publishing Co.

18920 S Quivira Rd.

Spring Hill KS 66083-8989