A note about our hub sitesIf you are looking for our McGill University program registration please visit our McGill University registration page, otherwise, please proceed belowMcGill University Registration Register Please enable JavaScript in your browser to complete this form.1Introduction2Important Information Before You Get Started3Demographic Information4Practice Characteristics5Statement of Collaboration6Case Presentation7Website RegistrationThank you for 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 info@echopaincanada.ca.. Next 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. I have reviewed the important information above *I agreeWhat kind of videoconferencing equipment will you be using to access for ECHO sessions? *DesktopLaptopTabletSmartphone (Android/ iOS)Unsure, please follow up with meECHO 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. NextName *FirstLastEmail *EmailConfirm EmailThis email will be used to receive future correspondence to connect to sessions and access resources.Phone Number *What province do you reside in? *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonWhat is your profession? *AdministratorMD – Physician PediatricianMD – Physician Family PhysicianMD – SpecialistPhysician AssistantNurse PractitionerRegistered NursePharmacistPsychologistSocial WorkerOccupational TherapistPhysiotherapist / Physical TherapistKinesiologist/Exercise CounsellorDieticianHealth Coach / Navigator (Child Life Specialist; Cancer Coach)Other (please specify)What is your profession? (Other – please specify) *How many years have you been in practice? *What is your age group? *20-2930-3940-4950-5960-6970-7980+What is your current gender identity? *MaleFemalePrefer not to sayOther – please describeWhat is your current gender identity – Other (please describe) *NextPractice / Organization Name *Practice Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeCanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry1. Approximately how many patients are registered in your practice right now? *2. Approximately what percentage of your patients would you describe as disadvantaged? (e.g. receiving social assistance such as ODSP) *3. What percentage of patients in your practice have chronic pain? *4. We are trying to gather a sense of what patient population you serve. Approximately what percentage of your practice would you describe as *Aboriginal ……. (%)Ethnic minorities ……. (%)Francophone ……. (%)Refugee ……. (%)Immigrants ……. (%)Prison inmates ……. (%)Veterans ……. (%)Group homes ……. (%)Long-term care homes ……. (%)Other?Aboriginal % *Ethnic Minorities % *Francophone % *Refugee % *Immigrants % *Prison Inmates % *Veterans % *Group home % *Long Term Care Home % *Other population % *5. How many NEW patients with chronic pain would you be willing to accept in your practice over the next year? *6. In the last 12 months, approximately how many referrals to a chronic pain specialist did you make? *7. In the last 12 months, approximately how many referrals to multidisciplinary pain clinics did you make? *8. In the last 12 months, approximately how long do your patients wait to be seen by these pain specialists? *9. How many years have you been in practice? *10a. What practice model do you practice in? *Solo PractitionerGroup PracticeLong-Term Care FacilityAboriginal Health CentreNurse Practitioner-Led ClinicHospital: Emergency department, in-patient care, out-patient clinicAcademic setting (University, college, etc.)Other, please specify:10a. Other, please specify *10b. If applicable, please indicate your secondary practice * (If more than one, please elaborate under "Other") *Solo PractitionerGroup PracticeLong-Term Care FacilityAboriginal Health CentreNurse Practitioner-Led ClinicHospital: Emergency department, in-patient care, out-patient clinicAcademic setting (University, college, etc.)Other, please specify:Not applicable10b. Other, please specify *11. What type of environment do you practice in? (Select all that apply. If more than one, please elaborate under "Other") * *Remote (defined as areas without year-round road access, or which rely on a third party such as an airplane or ferry for transportation to a larger centre)Rural (defined as areas with a population of less than 30,000 that are more than 30 minutes away from a community with a population of more than 30,000)Suburban/Urban (defined as areas with populations over 30,000)Other (please specify below)What type of environment (Other) *12. In which country did you complete your professional training? *CanadaOutside of CanadaOther (please specify)Professional Training (Other) *13a. About how much training did you have in chronic pain management during your professional training (e.g. Pharmacy School) ? (hours/days/months) *13b. About how much training did you have in chronic pain management during your post-graduate training (e.g. Residency, Practicum) ? (hours) *13c. About how much training did you have in chronic pain management after graduation (e.g. CME, CPD events, etc.) ? (hours/days/months) *14. Approximately how many patients do you have in your practice right now? *15. How did you hear about ECHO? *ConferencePresentationColleagueAn ECHO staff/team memberAn email/articleYour LHINAn ECHO participantA colleagueInternetOther: (please specify)How did you hear about ECHO (Other, please specify) *NextPlease 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. Statement of Collaboration *I agree to these terms of collaboration.Signature * Clear Signature Date *Next 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. Please select an option *Unsure/I have questions. Please follow up with me to schedule the case.I have selected my case dates, belowPotential Presentation Date *Potential Presentation Date (Second choice) *Next Project ECHO at UHN utilizes web-based resources to efficiently distribute materials. These materials include access to the discussion board, archive, didactic presentations, videos, events and more. Please fill in the following fields to create your username and password for the website, and your email address indicated earlier will be used to create your account. Password *PasswordConfirm PasswordWhat happens next? You will receive an email shortly with the following: Confirmation of your start date and case date The ECHO Pre Impact questionnaire Case Presentation Form Your ECHO website login information You will receive the weekly ECHO e-agenda on the day prior to your start date The e-agenda has the Link to join ECHO session. Submit