Register – ECHO Pain & Substance Use Disorder McGill

Register (McGill University)

Introduction - Step 1 of 8

Thank you for your interest in Project ECHO at McGill University.

We’d like to learn a little bit more about you, your interest in Project ECHO Canada, and your practice. By completing this form, you consent for your information to be used to better inform and tailor our program to suit your needs.

Please allocate approximately 15 minutes to complete this form.

If you have any questions or troubles with our registration process, please contact us at rebecca.binik@mcgill.ca

Please note that there are certain conditions which must be agreed to if you are selected to participate in this ECHO at McGill University 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. McGill University 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 at McGill University. 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 McGill University 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 McGill University collects participation data for each participating ECHO site. This data allows ECHO Pain Canada at McGill University 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.

Statement of Collaboration *

I agree to these terms of collaboration.

Signature *

Clear Signature

Date *