Soft-launch (pilot evaluation of CMC Curriculum) Recruitment Sign Up Form

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* 1. What is your Full name?

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* 2. What is your email that we can contact you at?

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* 3. What is your preferred language?

English

French

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* 4. Select the jurisdiction or jurisdictions that reflects the location of your clinical practice.

You can select more than one if applicable.

Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and Labrador

Nova Scotia

Ontario

Prince Edward Island

Quebec

Saskatchewan

Northwest Territories

Nunavut

Yukon

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* 5. What organization are you affiliated with?

Canadian Nurses Association (CNA)

Nurse Practitioner Association of Canada (NPAC)

College of Family Physicians Canada (CFPC)

Society of Rural Physicians of Canada (SRPC)

Royal College of Physicians and Surgeons of Canada (RCPSC)

La Fédération des médecins omnipraticiens du Québec (FMOQ)

Collège des médecins du Québec (CMQ)

Fédération des médecins spécialistes du Québec (FMSQ)

Other (please specify)

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* 6. Are you a:

MAiD Assessor AND Provider

MAiD Assessor only

Neither MAiD Assessor or Provider

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* 7. Are you a:

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* 8. How would you describe your experience with MAiD?

I have been involved with <10 cases in my career

I have been involved with >10 cases in my career

I am MAiD Naive

N/A

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* 9. Are you a Palliative Care Clinican?

Yes

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* 10. We would like you to participate in all module pilot evaluations for consistency. If not possible please select all of the modules that you will be willing to review and evaluate.

Foundations of MAiD in Canada

Clinical Conversations (MAiD)

How to do a MAiD Assessment

Providing MAiD

Navigating Complex Cases with Confidence

MAiD & Mental Disorders

Assessing Capacity & Vulnerability

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* 11. Do you identify as:

First Nations

Inuk

Metis

Asian

Black

Hispanic or Latino

White

Other

Two or more of the above

Prefer not to say

Soft-launch (pilot evaluation of CMC Curriculum) Recruitment Sign Up Form

Question Title

* 1. What is your Full name?

Question Title

* 2. What is your email that we can contact you at?

Question Title

* 3. What is your preferred language?

Question Title

* 4. Select the jurisdiction or jurisdictions that reflects the location of your clinical practice.You can select more than one if applicable.

Question Title

* 5. What organization are you affiliated with?

Question Title

* 6. Are you a:

Question Title

* 7. Are you a:

Question Title

* 8. How would you describe your experience with MAiD?

Question Title

* 9. Are you a Palliative Care Clinican?

Question Title

* 10. We would like you to participate in all module pilot evaluations for consistency. If not possible please select all of the modules that you will be willing to review and evaluate.

Question Title

* 11. Do you identify as:

* 4. Select the jurisdiction or jurisdictions that reflects the location of your clinical practice.

You can select more than one if applicable.