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Project ECHO MHSU in IHA - Cycle 1 Registration Form

Thank you for your interest in Project ECHO MHSU in Interior Health.

This registration form is for the "Management of MHSU Patients in Emergency Situations" series.

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 5 minutes to complete this form.

If you have any questions or troubles with our registration process, please contact us at echo@interiorhealth.ca

Important information before you get started

ECHO MHSU will connect you with an inter-professional specialist team and other primary care providers from across IH by videoconference. Each weekly session includes case-based discussions and a short didactic.  Each session is eligible for 1.5 MOC Section 1 (per session) Group Learning credits and has been certified by UBC CPD for up to 1.5 Mainpro+ (per session) Group Learning credits.



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 as many ECHO sessions as possible (there are 4 bi-weekly sessions) 

- Submit a case to present at one of the sessions 

- Complete 2 questionnaires (Pre and Post-ECHO) and Weekly Satisfaction Surveys following each ECHO session)

ECHO MHSU in IHA is fully funded by the Canadian Red Cross.

I have reviewed the important information above:

I agree

Unsure, please follow up with me

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What kind of videoconferencing equipment will you be able to access for ECHO sessions?

Desktop

Laptop

Tablet

Smartphone (Android/iOS)

Unsure, please follow up with me

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First Name

* must provide value

Last Name

* must provide value

Phone Number

Practice / Organization Name

* must provide value

City / Location of your Primary Work Place

* must provide value

Postal Code

* must provide value

What is your profession?

* must provide value

Family Physician

Nurse Practitioner

Other

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Please specify

* must provide value

How many years have you been in practice?

What is your age group?

20-29

30-39

40-49

50-59

60-69

70-79

80+

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What is your current gender identity?

Female

Male

Prefer not to respond

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What type of environment do you practice in?

* must provide value

I work in rural and remote area

I work in an area that experienced wildfires in 2017

I work in a MHSU under-serviced area

I work predominately with aboriginal populations

I work predominately with underserved or hard to reach populations that do not have access to MHSU Services

Other

Please specify

* must provide value

Please indicate your primary practice setting:

Solo Practitioner

Family Health Group / Clinic

Community Health Center

Aboriginal Health Center / Clinic

Nurse Practitioner Led Clinic

Remote Nursing Station

Other, please specify

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Please specify

* must provide value

Please specify

I am able to present a case on the following date (s):

January 29

February 12

February 26

March 11

STATEMENT OF COLLABORATION

Please note that there are certain conditions which must be agreed to when you participate in an ECHO program. Please indicate if you agree with the following statements (all must be agreed to):

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  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) de-identified patient case if selected.

Recording, Photographs and Guests:

 The ECHO team may occasionally record the session(s) for educational purposes and may take photos for promotional purposes. I give permission for my photos to be used unless explicitly requested in writing to echo@interiorhealth.ca.

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.

Attachment:Statement-of-Collaboration_2019-11-13.pdf

By signing I acknowledge the Statement of Collaboration.

* must provide value

Add signature

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