Please print this evaluation form, write down appropriate answer on each question and Fax to 972-245-8888

PARTICIPANT EVALUATION FORM

_________________________________              ____________________________________

                CAE Provider Name                                               Date(s) of Program or Course

_________________________________              ____________________________________

                Program/Course Title                                                         Instructor Name

_________________________________              ____________________________________

Participant¨s Name and License Number                                           Date of Evaluation

Did this course meet its stated objectives?・・・・・・・・・・・・・・・.. ・・.・ Yes                No

Did the instructor demonstrate adequate knowledge of the course subject?・・・・・・..Yes            No

Did the instructor utilize appropriate teaching methods and was easy to use?・・・・・・Yes          No

Do you feel that you will be able to apply what you have learned today to your practice?.. Yes        No

Would you recommend this on-line course to other licensed acupuncturists?・・..Yes       No

Additional Comments:

If you have a complaint about this course, you may contact the Texas State Board of Acupuncture Examiners at:

TSBAE

PO Box 2018

Austin, TX 78768-2018