CAEP Member: Preliminary Consultation Questions Respondent Information Question Title * 1. Contact First Name Last Name Email Address Phone Number Question Title * 2. I am a Medical Student Resident Staff Physician Other (please specify) Question Title * 3. Gender Female Male Gender Diverse Prefer not to disclose Question Title * 4. Which race category best describes you? Check all that apply: Black (African, Afro-Caribbean, African Canadian descent) East/Southeast Asian (Chinese, Korean, Japanese, Taiwanese descent or Filipino, Vietnamese, Cambodian, Thai, Indonesian, other Southeast Asian descent Indigenous (First Nations, Métis, Inuk/Inuit) Latino (Latin American / Hispanic descent) Middle Eastern (Arab, Persian, West Asian descent (e.g., Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish) South Asian South Asian descent (e.g., East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean) White European descent Another race category (Includes values not described above or Do not know, not applicable, prefer not to answer) Question Title * 5. Province or Territory of Practice (select all that apply) Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Northwest Territories Nunavut I practice outside of Canada Question Title * 6. If you are a staff physician, how many years have you been practicing 1-5 6-15 16-25 25+ Question Title * 7. Certification/training stream CCFP CCFP(EM) FRCPC Other (please specify) Question Title * 8. Location of practice (select all that apply) Urban Community Urban Academic Rural, Remote or Small Urban (population less than 30,000 people) Question Title * 9. Type of practice (i.e. in your practice location what is the scope of your practice) Question Title * 10. I would like to participate in an interview style consultation Yes No Next