Continuing Medical Education
Morton Plant Hospital (MS 611)
807 N. Myrtle Avenue
Clearwater, FL  33755
727-467-2517 Phone
727-467-2459 Fax

Complete and return to receive CME credit

Domestic Violence
Not Valid For CME Credit After October 1, 2020


Jessica Dickerson, Prevention Advocate CASA

All fields in red are mandatory



If you are new to our CME Program, or if your status has changed, please complete this section of the form.


Street Address:
City: , State: Zip:

Were the objectives of this educational activity met?
Yes No N/A
1. Define intimate partner violence/domestic violence, particularly in the state of Florida.  Discuss the statistics related to intimate partner violence/domestic violence.
2. Describe the consequences of violence.  Identify risk factors related to being a victim of violence and for being a perpetrator of violence.

3. Describe how to initiate the topic of intimate partner violence/domestic violence with your patients.  Discuss interventions and identify resources in Florida related to intimate partner/domestic violence.
4. Overall, was the speaker(s) knowledgeable regarding the content?  If no, please explain:  
5. Was there an opportunity to discuss practice-relevant issues with the speaker(s)? If no, please explain:  
6. Do you feel the activity was scientifically sound and free of commercial bias* or influence?  If no, please explain:  
*Commercial bias is defined as a personal judgment in favor of a specific product or service of a commercial interest.
7. Please identify how you may improve your competence and/or performance as a result of attending this activity (select all that apply):
This activity validated my current practice; no changes will be made
Create/revise protocols, policies, and/or procedures
Change the management and/or treatment of my patients
Other, please specify:

8. How might the format of this activity be improved for the content presented (select all that apply)?
  Format was appropriate; no changes needed
  Include more case-based presentations
  Increase interactivity with attendees
  Add breakouts for subtopics
  Schedule more time for Q & A
  Add a hands-on instructional component
Other, describe:
9. Please describe any clinical situations that you find difficult to manage or resolve that you would like to see addressed in future educational activities:   


Question 1       Domestic violence only happens to women
      A      True
      B      False
Question 2       It takes a survivor an average of 7 times to leave an abusive relationship before the survivor is able to leave for good
      A      True
      B      False
Question 3       Coersion, intimidation, emotional abuse, isolation, minimizing and denying, using the children, using privilege, economic abuse, physical abuse and sexual abuse are all forms of Power and Control
      A      True
      B      False

Morton Plant Mease Health Care is accredited by the Florida Medical Association to provide continuing medical education for physicians.

Morton Plant Mease Health Care designates this activity for a maximum of 1.0 AMA PRA Category 1 Credits™.  Physicians should claim credit commensurate with the extent of their participation in the activity.