- Step 1 of 8Project ECHO at UHN RegistrationThank you for your interest in Project ECHO at UHN. This registration form is for ECHO Chronic Pain, Liver and Rheumatology programs. *For ECHO Concussion, please return to the top menu and select Concussion. *For ECHO COVID-19 registration, please return to top menu and select COVID-19. We’d like to learn a little bit more about you, your interest in Project ECHO, 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 echo.ontario@uhn.ca If you are an existing participant in one of our ECHOs (Rheumatology, Liver, Chronic Pain) please Click Here to use our short form. Otherwise, continue with this form. NextImportant Information before you get startedECHO will connect you with an inter-professional specialist team and other primary care providers from across Ontario 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 20 curriculum topics. Please join as often as possible.) Present at least 1 case (All cases are de-identified.) Complete 2 questionnaires (Pre-Impact questionnaire will be sent to you before you start and Impact questionnaire is sent after attending 8-10 sessions.) ECHO at UHN is fully funded by the Ministry of Health I have reviewed the important information above *I agreeWhat kind of videoconferencing equipment will you be able 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 *FirstLastE-mail *EmailConfirm EmailThis email will be used to receive future correspondence to connect to sessions and access resources.Phone Number *Demographic InformationWhat is your profession? *AdministratorMD - Physician Family PhysicianMD - Specialist (Please specify below)Physician AssistantNurse PractitionerRegistered NursePharmacistPsychologistSocial WorkerOccupational TherapistPhysiotherapist / Physical TherapistKinesiologist/Exercise CounsellorDieticianHealth Coach / Navigator Other (Please Specify)Profession - Other(please specify)How may years have you been in practice? *What is your age group? *20-29 years30-39 years40-49 years50-59 years60-69 years70-79 years80+ yearsWhat is your current gender identity? *Prefer not to respondFemaleMaleDifferent identity (please describe below)Gender - Other(please specify)PreviousNextPractice / Organization Name *Practice Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePlease indicate your type of practice *Solo PractitionerFamily Health GroupFamily Health Team (Family Health Network/Family Health Organization)Non-FHT (Family Health Network/Family Health Organization)Community Health CentreCommunity Health Agency – please specifyLong-Term Care FacilityAboriginal Health Access CentreNurse Practitioner Led ClinicHospital: Emergency department, in-patient care, out-patient clinic – please specifyUniversityOther (please specify)Primary Practice - Other(please specify)If applicable, please indicate your secondary practice *Solo PractitionerFamily Health GroupFamily Health Team (Family Health Network/Family Health Organization)Non-FHT (Family Health Network/Family Health Organization)Community Health CentreCommunity Health Agency – please specifyLong-Term Care FacilityAboriginal Health Access CentreNurse Practitioner Led ClinicHospital: Emergency department, in-patient care, out-patient clinic – please specifyUniversityOther(Please Specify)Not ApplicableSecondary Practice - Other(please specify)What LHIN are you a part of? (Select all that apply) *01 - Erie St. Clair02 - South West03 - Waterloo Wellington04 - Hamilton Niagara Haldimand Brant05 - Central West06 - Mississauga Halton07 - Toronto Central08 - Central09 - Central East10 - South East11 - Champlain12 - North Simcoe Muskoka13 - North East14 - North WestI am not sure (please indicate your city/town below)Not applicableLHIN - Other(please specify)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)Environment - Other(please specify)Approximately how many patients do you have in your practice right now? *How did you hear about ECHO? *ConferencePresentationColleagueAn ECHO Staff/team member, who?An email or article, which oneYour LHINAn ECHO participantOne of your family health team matesInternetOtherPlease provide further details (eg. which conference, or presentation, etc)PreviousNextWhich Project ECHO at UHN would you like to register for? *Chronic Pain, every Thursday from 12:30PM - 2:00PM ESTRheumatology, every Friday from 12:00PM - 1:30PM ESTLiver, every Monday from 12:00PM - 1:30PM ESTWhen are you available to start? *PreviousNextPlease 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): The statement of collaboration may be downloaded by clicking Here 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) deidentified 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 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 “Solo Practitioner”. Any quotes that may be shared outside of MOH reporting will be identified as “[Profession], [ECHO Name]”. 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’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. Statement of CollaborationAgreement of Collaborating with Community Partners: * I agree to these terms of collaboration.Signature *Clear SignatureSOC - Date *PreviousNextCase Presentation: Select Potential datesCase 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. All cases relevant to the specific program topic (pain, liver, opioids, rheumatology) are invited. In the space below, please identify at least one case date, on the appropriate week day (Liver Mondays, Chronic Pain/Opioids Thursdays, Rheumatology Fridays). We recommend that you select a date 3-6 weeks from your start date. We will follow up with date confirmation, case form, and instructions after you’ve submitted this form. 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 ChoicePreviousNextWebsite Account RegistrationProject 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 Please press "Submit" to finalize your registration. Thank you for your interest in Project ECHO.Username *Password *PasswordConfirm PasswordCaptcha * = What 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 log in 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. Email *Email *CommentSubmit