Please complete the questions below. This information is required for our accreditation application to the College of Family Physicians of Canada.

Keynote speakers: please complete the questionnaire twice - once for your keynote and once for your workshop.
PRESENTER's INFORMATION

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* 1. First Name

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* 2. Last Name

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* 3. Email address

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* 4. Phone number

CO-PRESENTER’s INFORMATION (IF APPLICABLE)

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* 5. First name

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* 6. Last name

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* 7. Email

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* 8. Phone number

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* 9. Is the co-presenter a physician?

SESSION INFORMATION

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* 10. Session Title

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* 11. Brief description
Will be used on the website and in the registration system. (250 words maximum) 
Click the right bottom corner of the box to expand the comment box.

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* 12. Learning objectives: Minimum of 3

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* 13. Identify which CANMeds roles will be addressed in your workshop (check all that apply). Definitions are provided below this question.

CANMEDS ROLES DEFINITIONS

Medical expert: knowledge, clinical and/or procedural skills
Communicator: effective doctor/patient relationships.
Collaborator: working effectively within a health care team.
Leader: collaborative leadership and management
Health Advocate: developing expertise and influence to advocate for the health and well-being of patients, communities and/or populations.
Scholar: lifelong reflective learning as well as creating, disseminating, applying and translating medical knowledge.
Professional: ethical practice, adherence to professional regulations and personal high standards of care.

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* 14. How will you make this workshop interactive and engage the participants? (Reminder, at least 25% of the 75-minute workshop must be interactive).

CONFLICT OF INTEREST (COI)

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* 15. I understand and agree that completed COI forms are required from ALL presenters. The link to complete your COI will be available once you click submit below - and it is in the same email that this link was in. If applicable, please share this link with your co-presenter.

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