Please enable JavaScript in your browser to complete this form.Demographic Information - Step 1 of 3Name *FirstLastEmail *EmailConfirm EmailWe encourage you to use a personal email address as work/private institution addresses could delay or prevent you from receiving the activation emailPassword *PasswordConfirm PasswordPlease use a different password than your usual password as your account details will be emailed to you.What is your age group? *20 - 29 years30 - 39 years40 - 49 years50 - 59 years60 - 69 years70 - 79 years80+ yearsWhat is your Gender Identity? *Prefer not to respondFemaleMaleTransgenderDifferent Identity (please describe below)Gender - Other (please specify)Please select your language preference: *EnglishFrenchHow did you hear about this program *ConferencePresentationColleagueAn email or article (please specify)LHINInternetOne of your family health team managersOtherPlease provide further details (eg. which conference, or presentation, etc)Please select the option that best describes your role (select one): *Physician - General PractitionerPhysician - SpecialistDentistNurse PractitionerPharmacistPhysician AssistantOther, please specifyRole - Other (please specify)What city is your practice located in? *What Province/Territory is your practice located in? *OntarioQuebecNova ScotiaNew BrunswickManitobaBritish ColumbiaPrince Edward IslandSaskatchewanAlbertaNewfoundland and LabradorNorthwest TerritoriesYukonNunavutWhat is the postal code of your practice? *What type of environment do your 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)Urban (defined as areas with populations over 30,000)Other (please specify)Type of environment practiced in - Other (please specify)NextPlease select the range of length of time you have been in practice? *Less than 1 year1-3 years3-5 years5+ yearsN/ADo you practice in a solo or team practice setting? *SoloTeamN/ADo you practice in a Community or Academic Setting? *CommunityAcademicN/APlease select the number of patients you have in your practice right now: *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/APlease select the approximate percentage of your patients prescribed long-term opioids for chronic non-cancer pain: *Less than 1%1%-20%21%-40%41%-60%61%-80%81%-95%More than 96%N/ANext Consent to Participate in Research: 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 *I consent to participate in researchI do not consent to participate in researchName *FirstLastSignature *Clear SignatureEmailSubmit