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Project ECHO at UHN Registration and Orientation

Thank you for your interest in Project ECHO at UHN.

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.

You MUST complete both Registration & Orientation before submitting. Please allocate approximately 15 minutes to complete this.

Name *

First

Last

E-mail *

Confirm Email

Phone Number *

Demographic Information

What is your profession? *

Profession - Other(please specify)

How may years have you been in practice? *

What is your age group? *

What is your current gender identity? *

Gender - Other(please specify)

Practice / Organization Name *

Practice Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Please indicate your primary practice setting *

Primary Practice - Other(please specify)

If applicable, please indicate your secondary practice setting *

Secondary Practice - Other(please specify)

What LHIN are you a part of? (Select all that apply) *

01 - Erie St. Clair
02 - South West
03 - Waterloo Wellington
04 - Hamilton Niagara Haldimand Brant
05 - Central West
06 - Mississauga Halton
07 - Toronto Central
08 - Central
09 - Central East
10 - South East
11 - Champlain
12 - North Simcoe Muskoka
13 - North East
14 - North West
I am not sure (please indicate your city/town below)
Not applicable

LHIN - 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? *

How did you hear about ECHO? (please specify)

Which Project ECHO at UHN would you like to register for? *

Chronic Pain, every Thursday from 12:30PM - 2:30PM EST
Rheumatology, every Friday from 12:00PM - 2:00PM EST
Liver, every Monday from 12:00PM - 1:30PM EST

When are you available to start? *

Please note that there are certain conditions which must be agreed to if you are selected to participate in this ECHO 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 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
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
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.

In order to support the growth of ECHO, Project ECHO® collects participation data for each ECHO™ program. This data allows Project ECHO to measure, analyze, and report on the reach of ECHO. It may be used in reports, on maps and visualizations, for research, for communications/promotions and surveys, for data quality assurance activities, and for decision-making related to new initiatives.

Statement of Collaboration

Agreement of Collaborating with Community Partners: *

I agree to these terms of collaboration.

Signature *

SOC - Date *

Once you are finished with this module, press the 'Continue with the registration Form' on the bottom of the screen to continue with the form

Case Presentation: Select Potential dates

Case presentations are an integral part of the ECHO Ontario sessions. Every week, an ECHO participant introduces a case in order to support our case-based learning approach.

If you currently have a case in mind that you would like to present for feedback, please select a date below. Otherwise we will be in contact soon to schedule your case presentation date.

Potential Presentation Date: *

Potential Presentation Date: Second Choice *

Potential Presentation Date: Third Choice *

Website Account Registration

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

Please press "Submit" to finalize your registration. Thank you for your interest in Project ECHO.

Username *

Password *

Password

Confirm Password

Captcha *

Website

Project ECHO at UHN Registration and Orientation

Demographic Information

Statement of Collaboration

Once you are finished with this module, press the 'Continue with the registration Form' on the bottom of the screen to continue with the form

Case Presentation: Select Potential dates

Website Account Registration

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