{"id":130,"date":"2021-07-18T15:14:14","date_gmt":"2021-07-18T19:14:14","guid":{"rendered":"https:\/\/echopaincanada.ca\/?page_id=130"},"modified":"2021-07-18T15:14:59","modified_gmt":"2021-07-18T19:14:59","slug":"program-evaluation-consent","status":"publish","type":"page","link":"https:\/\/echopaincanada.ca\/fr\/program-evaluation-consent\/","title":{"rendered":"Program evaluation consent"},"content":{"rendered":"\n<div style=\"height:20px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\">Program evaluation consent<\/h2>\n\n\n<div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume wpforms-block\" id=\"wpforms-95\"><form id=\"wpforms-form-95\" class=\"wpforms-validate wpforms-form\" data-formid=\"95\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/130\" data-token=\"14ba0326e61d3c60263ae4502cd52524\" data-token-time=\"1782354308\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-95-field_3-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"3\"><div id=\"wpforms-95-field_3\"><p><b>Consent to Participate in Program Evaluation<\/b>\r\n<br \/>\r\n<br \/>The availability of this free CME accredited ECHO Canada Pain session (inset hub site name ex. at McGill University) is made possible by grant funding from Health Canada\u2019s Substance Use and Addictions Program. In order to report on the effectiveness and value of the program, Dr. Andrea Furlan\u2019s team at the University Health Network will be collecting aggregate data from all participants completing the ECHO Canada Pain sessions. We will be collecting and analyzing data from participant demographic information, pre-questionnaires and post-questionnaires. No personal identifying information will be used in any reporting or publications. All data will be securely stored at the University Health Network-Toronto Rehabilitation Network for a period of 10 years and will only be accessed by Dr. Andrea Furlan and her project team. Data can be withdrawn at any time by informing Dr. Andrea Furlan. <br \/><br \/>  \r\nIf you have any questions about this program evaluation study please contact the Program Manager, Yalnee Shantharam, at yalnee.shantharam@uhn.ca or 416-597-3422 x 3276.   If you have any questions about your rights as a participant in this program evaluation study, you may contact the University Health Network\u2019s Quality Improvement Review Committee (QIRC) at QI@uhn.ca \r\n\r\n<\/p><\/div><\/div><div id=\"wpforms-95-field_6-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"6\"><ul id=\"wpforms-95-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-95-field_6_1\" name=\"wpforms[fields][6]\" value=\"I consent to participate in program evaluation study\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-95-field_6_1\">I consent to participate in program evaluation study<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-95-field_6_2\" name=\"wpforms[fields][6]\" value=\"I do not consent to participate in program evaluation study\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-95-field_6_2\">I do not consent to participate in program evaluation study<\/label><\/li><\/ul><\/div><div id=\"wpforms-95-field_8-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"8\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-95-field_8\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][8][first]\" required><label for=\"wpforms-95-field_8\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-95-field_8-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][8][last]\" required><label for=\"wpforms-95-field_8-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-95-field_9-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-95-field_9\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-95-field_9\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][9]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-95-field_9-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 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