Please enable JavaScript in your browser to complete this form.Informations démographiques - Étape 3 de 3 This course does not include an accreditation certificate. It only includes a certificate of completion. Learners include: medical residents, fellows, nurse practitioner students, pharmacy students and other students. Nom *PrénomNom de familleCourriel *CourrielConfirmez votre courrielNous vous encourageons à utiliser un courriel personnel, car les courriels professionnels ou d’institution privée pourraient retarder ou vous empêcher de recevoir le courriel d'activation.Mot de passe *Mot de passeConfirmez votre mot de passeVeuillez utiliser un mot de passe différent de votre mot de passe habituel, car les détails de votre compte vous seront envoyés par courriel.Quel est votre group d’âge? *20 - 29 years30 - 39 years40 - 49 years50 - 59 years60 - 69 years70 - 79 years80+ yearsQuel est votre identité de genre? *Prefer not to respondFemaleMaleTransgenderDifferent Identity (please describe below)Gender - Other (please specify)Veuillez sélectionner votre langue de préférence *EnglishFrenchComment avez-vous entendu parler de ce programme? *ConferencePresentationColleagueAn email or article (please specify)LHINInternetOne of your family health team managersOtherPlease provide further details (eg. which conference, or presentation, etc)Veuillez sélectionner l’option qui décrit le mieux votre rôle (en sélectionner une) *Undergraduate Medical StudentResidentFellowMedical EducatorNurse Practitioner StudentPharmacy StudentOther, please specifyRole - Other (please specify)Student Number *Program Name *Academic Institution *What city is your practice or study located in? *What Province/Territory is your practice or study located in? *OntarioQuebecNova ScotiaNew BrunswickManitobaBritish ColumbiaPrince Edward IslandSaskatchewanAlbertaNewfoundland and LabradorNorthwest TerritoriesYukonNunavutWhat is the postal code of your practice or study? *What type of environment do your practice or study 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)Urban (defined as areas with populations over 30,000)Other (please specify)Type of environment practiced in - Other (please specify)SuivantVeuillez sélectionner le temps que vous êtes en pratique? *Moins de 1 an1-3 ans3-5 ans5+ ansN/APratiquez-vous en solo ou en équipe? *SoloÉquipeN/APratiquez-vous en milieu communautaire ou académique? *CommunautéAcadémiqueN/AVeuillez sélectionner le nombre de patients que vous avez actuellement dans votre cabinet médical: *Less than 500 patients500-1,000 patients1,000-1,500 patients1,500-2,000 patients2,000-2,500 patients2,500-3,000 patientsMore than 3,000 patientsN/AVeuillez sélectionner le pourcentage approximatif de vos patients qui ont reçu des opioïdes à long terme pour une douleur chronique non cancéreuse: *Moins de 1%1%-20%21%-40%41%-60%61%-80%81%-95%Plus de 96%N/ASuivant Consentement à participer à la recherche In order to report on the effectiveness of the program, Dr. Andrea Furlan’s research team at the University Health Network will be collecting aggregate data from all participants completing the course. We will be collecting and analyzing data on the following information: participant demographic information, practice location & size, pre-SAP test scores, post-SAP test scores, and accreditation survey results. Study participants will be identified in our databases using a unique study ID. A separate linking log with ID numbers corresponding with name and contact information will be kept in an encrypted file on a secure server for reference by our study staff only. No personal identifying information will be used in any reporting or publications. All data will be securely stored at the University Health Network for 7 years and only be accessed by Dr. Andrea Furlan and her research team. Request to Withdrawal: If you decide to leave the study, you have the right to request withdrawal of information collected about you. Let study project manager know by emailing Nagina Parmar at nagina.parmar@uhn.ca or info@opioidassessment.ca or by calling at 437-238-8467. The University Health Network Research Ethics Board has reviewed this protocol. If you have any questions or clarifications regarding the study, please reach out to our study project manager Nagina Parmar at nagina.parmar@uhn.ca or info@opioidassessment.ca or by calling at 437-238-8467. In addition, if you have any questions about your rights as a research participant, you may contact 416-581-7849 or email reb@uhnresearch.ca. Please note that communication via e-mail is not absolutely secure. Thus, please do not communicate personal sensitive information via e-mail. Consent Choice *Je consens à participer à la rechercheI do not consent to participate in researchNom *PrénomNom de familleWebsiteSubmit
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