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Merci pour votre intérêt au Projet ECHO Canada et votre pratique. En remplissant ce formulaire, vous consentez à ce que vos informations soient utilisées pour mieux informer et adapter notre programme à vos besoins.

Veuillez prévoir environ 15 minutes pour remplir ce formulaire.

Si vous avez des questions ou des problèmes avec notre processus d’inscription, veuillez nous contacter à info@echopaincanada.ca.

ECHO will connect you with an inter-professional specialist team and other primary care providers from across your province/region by videoconference. Each weekly session includes case-based discussions and a short didactic.

There is no charge to attend but we ask that you actively engage in the peer learning community by sharing case presentations and ideas with the group.

Participants are asked to:
• Attend ECHO sessions (There are 10-12 curriculum topics. Please join as often as possible.)
• Present 1 case (All cases are de-identified.)
• Complete 2 questionnaires (Pre-Questionnaire will be sent to you before you start and Post-Questionnaire is sent after attending 5 sessions.)

ECHO Canada Chronic Pain and Substance Use Disorder is fully funded by Health Canada.

ECHO uses ZOOM, a free videoconference platform. You may download it from www.zoom.us. You will need internet access, speakers, microphone (and a camera) OR a telephone.

Please note that there are certain conditions which must be agreed to if you are selected to participate in this ECHO UHN program. Please indicate if you agree with the following statements (all must be agreed to):

• Patient Relationship Disclaimer: ECHO case presentations do not create or establish provider-patient client relationship between any ECHO Hub Clinician and a patient whose case is presented.
• Commitment to Collaboration: Recommendations from the Hub do not in any way replace my own diligence and professional expertise with respect to my patients or clients. University Health Network and its officers, directors, employees, subcontractors and agents accept no responsibility or liability for any treatment decisions I make as a result of my participation, or association with ECHO UHN. I agree to be solely responsible for the treatment of my patients and understand that all clinical decisions rest with me regardless of recommendations provided by the expert hub team and other ECHO participants.
• De-identified Information Notice and Confidentiality: Personal identifying information is not to be shared during ECHO sessions. If this does occur, I’ll follow my own organization’s policies and procedures to address the privacy breach.
• Participation Notice: I and/or my organization (Spoke) will participate in as many sessions as possible during the curriculum to maximize my learning experience. I understand that case discussions are part of every session and that I, or a member of my team, will be expected to present at least 1 (one) de-identified patient case.
• Recording, Photographs, and Guests: The ECHO team records sessions for educational purposes and occasionally takes photos for promotional purposes. I give permission for my photos to be used unless explicitly requested in writing.


Data Use Notice: I understand that the following data will be collected for reporting purposes:

1. In order to meet Health Canada funding deliverables, ECHO Pain Canada at UHN and {insert hub site name} collects participant data for annual reports that are submitted directly to Health Canada. Participant data will always be anonymized.
2. In order to support quality improvement and quality assurance, the ECHO Pain Canada at UHN collects participation data for each participating ECHO site. This data allows ECHO Pain Canada at UHN to measure, analyze, and report on the model’s reach within each province. Your anonymized, aggregate data will be used in reports for quality improvement and quality assurance purposes.

Case Presentations are an integral part of ECHO sessions. There is no limit to the number of cases you can present, however we ask that all participants present at least 1 case.

• All cases are de-identified
• There is no patient doctor relationship established between the ECHO specialist team and your patient.
• Case presentations are mostly pre-scheduled, however you can reach out whenever you have case questions to schedule a more ‘spontaneous case’.
• Although most participants discuss their own patient cases, others present cases on behalf of their team.