Stage A. Evidence of Learning from Current Practice Performance Assessment

Office for Continuous Professional Learning MSC09 5370, 1 University of New Mexico Albuquerque, NM 87131 (505) 272-3942 https://hsc.unm.edu/medicine/education/cpl/

P/QI CME Number:

(P/QI-xxx)

Name of Participants*

Email Addresses*

1. What performance measures are you using for your current practice assessment?

If you plan to upload a document in response to this question, please indicate "document attached" in this field, and review the additional instructions in the left panel.

2. Specify the data source(s) you examined in your practice assessment, e.g., chart reviews, and attach a sample of any data collection form used.*

If you plan to upload a document in response to this question, please indicate "document attached" in this field, and review the additional instructions in the left panel.

3. Describe the outcome of your analysis of these data documenting current practice. Include the specific measureable improvement(s) that your project will address.*

If you plan to upload a document in response to this question, please indicate "document attached" in this field, and review the additional instructions in the left panel.

4. Has anyone joined the project since submit the Planning Form? If so, each person must complete and submit the Disclosure and Conflict of Interest form.*

If so, please provide us with their name in the space below.

Also, each person must complete and submit the Disclosure and Conflict of Interest form.

Attach a sample of any data collection form used.

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