California > Workers Comp > General
Industrial Medical Council Course Evaluation IMC-117 - California
| Industrial Medical Council Course Evaluation Form. This is a California form and can be used in General Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS INDUSTRIAL MEDICAL COUNCIL DWC - Medical Unit P.O. Box 420603 San Francisco, CA 94142 Tel. No.: (650) 737-2700 or 1-(800) 794-6900 Arnold Schwarzenegger, Governor Fax No.: (650) 737-2711 INDUSTRIAL MEDICAL COUNCIL COURSE EVALUATION As a part of the IMC's ongoing efforts to ensure that courses for Qualified Medical Evaluators offer valuable information on California Workers' Compensation-related medical evaluation issues, we are asking attendees of the IMC approved courses (including distance learning programs) to complete the following Course Evaluation. Date of Course: Maximum Course Hours Available Excellent Content of Hand-out material Accurate/Adequate new information Educational Objective Met Pertinence to QME evaluations Knowledge of presenters Syllabus Legibility Adequacy of Room Adequacy of Audio Visual Overall Rating 5 5 5 5 5 5 5 5 5 Course Provider: Hours Completed Good 4 4 4 4 4 4 4 4 4 Satisfactory 3 3 3 3 3 3 3 3 3 Fair 2 2 2 2 2 2 2 2 2 Poor 1 1 1 1 1 1 1 1 1 What improvement(s) would you suggest? TO ALL ATTENDEES: PLEASE RETURN THIS FORM TO THE IMC. All providers shall be required to provide this response form (postage paid) to all attendees and shall advise all attendees that the form should be promptly returned to the IMC at the address on the back of this form. IMC Form 117, Rev. 3/01/00 Note: Authority Cited: Reference: Section 139.2, Labor Code. Section 139.2, Labor Code IMC Regs-Form American LegalNet, Inc. www.USCourtForms.com
|
|||||||
