ECHO Ontario Skin and Wound Introductory Series on the Diabetic Foot

Background Information

This is the application form for Project ECHO Ontario Skin and Wound Introductory Series on the Diabetic Foot.

**Open to all Healthcare Professionals across Canada

Project ECHO (Extensions for Community Health Outcomes) Ontario Skin and Wound offers evidence-based mentorship and case-based learning on skin and wound care at no cost to Ontario health care providers. Project ECHO is based on a Hub and Spoke model. A resource team (Hub) comprising of physicians, nurses and allied health providers provide community partners (Spokes), with guidance on patients with complex skin and wound care needs. Spokes are comprised of health care professionals from across the province interested in expanding their knowledge in wound care. Continuing Medical Education (CME) credits will be rewarded to physicians.

A Spoke can be one or more health providers gathered at:

- A Family Health Team
- An Aboriginal Health Centre or a Community Health Centre
- A Long-Term Care Home
- A Hospital

- A Nursing Clinic

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* 1. What is your first and last name?

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* 2. What is your email address?

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* 3. What is your telephone number?

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* 4. What is the name of your Clinic/Organization?

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* 5. What City/Town/Village is your Clinic/Organization based in?

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* 6. What is the Postal Code of your Clinic/Organization? Skip if unknown

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* 7. I practice in:

British Columbia

Prairies (Alberta, Saskatchewan & Manitoba)

Ontario

Quebec

Atlantic Canada (PEI, NS, NB & NL)

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* 8. If in Ontario, which LHIN/Region(s) do you perform skin and wound care in?

Central

Central West

Mississauga Halton

North West

North East

Champlain

Waterloo Wellington

Toronto Central

Erie St. Clair

Hamilton Niagara Haldimand Brant

South West

South East

Not Sure

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* 9. What is your profession?

Other (please specify)

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* 10. What is your area of practice specialty or expertise e.g. pediatrics, complex care, geriatrics?

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* 11. What is your primary practice setting?

Family Health Team

Community Health Centre

Aboriginal Health Access Centre

Nurse Practitioner Led Clinic

Primary Care Solo Practice

Home Care Provider

Home Care Clinic

Nursing Station

Community Hospital

Academic Hospital

Long Term Care

Other (please specify)

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* 12. Including yourself, how many team members would be joining you on these ECHO sessions?

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* 13. Select All of the Following Priority Areas that Apply to Your Organization

Urban (communities within and in close proximity to cities)

Rural (communities with a population of less than 30,000 that are greater than 30 minutes away in travel time from a community with a population of more than 30,000)

Remote (without year-round road access, or which rely on a third party (e.g. train, airplane, ferry) for transportation to a larger centre)

Northern

Working Towards Forming an Inter-professional Team or Already Within an Inter-Professional Team

Caring for Indigenous People

Caring for other Vulnerable Populations e.g. housing insecure

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* 14. Are you interested in attending the complete ECHO Skin and Wound sessions starting on September 7, 2022 - 2 cycles comprising 8 sessions in each cycle?
Cycle 1 - Leg and Foot Ulcers
Cycle 2 - Pressure injuries, post surgical and other wounds

Yes, I am interested in attending the complete ECHO Skin and Wound sessions

No, I am not interested at this time

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* 15. Are you interested in attending future Virtual Boot Camps for additional skills development?

Yes, I am interested in learning more about Virtual Boot Camps

No, I am not interested at this time

ECHO Ontario Skin and Wound Introductory Series on the Diabetic Foot

Background Information

Question Title

* 1. What is your first and last name?

Question Title

* 2. What is your email address?

Question Title

* 3. What is your telephone number?

Question Title

* 4. What is the name of your Clinic/Organization?

Question Title

* 5. What City/Town/Village is your Clinic/Organization based in?

Question Title

* 6. What is the Postal Code of your Clinic/Organization? Skip if unknown

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* 7. I practice in:

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* 8. If in Ontario, which LHIN/Region(s) do you perform skin and wound care in?

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* 9. What is your profession?

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* 10. What is your area of practice specialty or expertise e.g. pediatrics, complex care, geriatrics?

Question Title

* 11. What is your primary practice setting?

Question Title

* 12. Including yourself, how many team members would be joining you on these ECHO sessions?

Question Title

* 13. Select All of the Following Priority Areas that Apply to Your Organization

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* 14. Are you interested in attending the complete ECHO Skin and Wound sessions starting on September 7, 2022 - 2 cycles comprising 8 sessions in each cycle?Cycle 1 - Leg and Foot UlcersCycle 2 - Pressure injuries, post surgical and other wounds

Question Title

* 15. Are you interested in attending future Virtual Boot Camps for additional skills development?

* 14. Are you interested in attending the complete ECHO Skin and Wound sessions starting on September 7, 2022 - 2 cycles comprising 8 sessions in each cycle?
Cycle 1 - Leg and Foot Ulcers
Cycle 2 - Pressure injuries, post surgical and other wounds