Personal Information
Practice Information
Program Details
Statement of Collaboration
Next Steps

Personal Information

First Name

Last Name

Email Confirm

Phone Number

Programs

What is your Profession?

How many years have you been in practice

What is your age group

What is your current gender identity?

Other Gender

Practice / Organization Name

Practice Address

Postal Code

City

State / Province / Region

Indicate your type of Practice

If applicable, indicate your secondary practice

Which geographic region of Ontario do you practice in?

Please choose the region of Ontario (formerly LHINs) that best captures your practice area.*If this does not apply to you select "Not applicable"

What type of environment do you practice in?

Other Environment

Approximately how many patients in your practice?

Provide any Further Details

When are you available to start?

What type of environment do you practice in? (select all that apply)

Environment - Other (please specify)

Please give details

How did you hear about ECHO?

(For example, linkedin, association emails, facebook, twitter, colleague, etc)

Terms

The ECHO at UHN Statement of Collaboration (SOC) outlines certain conditions which must be understood and agreed to in order to participate in any of our ECHO programs. 
 
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 sessions do not in any way replace my own diligence and professional expertise with respect to my patients or clients. University Health Network (UHN) 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.

I Agree I have questions, please contact me

Terms

I Agree I have questions, please contact me

Terms

I Agree I have questions, please contact me

Terms

Data Use Notice: I understand that the following data will be collected for reporting purposes: 1. In order to meet Ministry of Health (MOH) funding deliverables, ECHO UHN collects participant data for quarterly and annual reports that are submitted directly to the MOH. Any public dissemination outside of the MOH is anonymized. If ECHO UHN shares any documents for use outside of MOH reporting, participant name will be removed but the name of the organization will be included. Those working independently will be identified as &ldquo;Solo Practitioner&rdquo;. Any quotes that may be shared outside of MOH reporting will be identified as &ldquo;[Profession], [ECHO Name]&rdquo;. 
 
2. In order to support quality improvement and quality assurance, the ECHO Ontario Superhub collects participation data for each ECHO program in Ontario, including ECHO UHN. This data allows ECHO Ontario to measure, analyze, and report on the model&rsquo;s reach within Ontario. Your data will be used in reports for quality improvement and quality assurance purposes. If shared for use outside of Superhub reporting, participant name will be removed but the name of the organization will be included. 3. In order to support the growth of the ECHO model, the Project ECHO Institute at the University of New Mexico, USA collects attendance for each ECHO program globally, including ECHO UHN. This data allows the Project ECHO Institute to measure, analyze, and report on the reach and impact of the program internationally. Your participation data, including name, organization name, organization address and ECHO session attendance, will be shared. Aggregated data (at a program level) will be used in reports, for quality assurance/improvement activities, and for decision-making related to new initiatives. If you would like to opt-out of this, please contact a member of our team. 
 
My participation data will be shared with the Ministry of Health, Ontario Superhub, and ECHO New Mexico as outlined above.

I agree I agree to have my data shared with the Ministry of Health and Ontario Superhub, but want to opt out of sharing with ECHO New Mexico. I have questions, please contact me