Palliative and End of Life Care Mentoring Network - Needs Assessment Survey

This survey serves as your online application to join the OCFP's online community of practice for Palliative and End of Life Care.

This community of practice is open to physicians – including family doctors and specialists – pharmacists and nurse practitioners in Ontario, facilitating access to palliative and end-of-life experts and peers for case-based support and education. It is part of the OCFP’s Collaborative Mentoring Networks, supported by the Ministry of Health and Long-Term Care. Email ocfpmentoring@ocfp.on.ca to learn more.

Later in this survey, you will have the opportunity to indicate your interest in joining the Palliative Care Collaborative Mentoring Network as a Mentor or Mentee, or participating in the Community of Practice only.

The survey collects demographic information about you and your practice as well as your learning needs for continuing medical education. The information you provide will help shape future program development. Thank you in advance for your participation.

About You

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* 1. Full name:

First name:

Last name:

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* 2. Active email address which you regularly check:

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* 3. Your year of birth:

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* 4. Years in practice:

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* 5. You are:

Male

Female

Other

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* 6. Please provide your CPSO, NPAO, OPA (or applicable professional association) number:

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* 7. In which way(s) would you like to participate in the Collaborative Mentoring Networks?
Please select all that apply.

Become a Mentor

Become a Mentee

Participate in the online Community of Practice

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* 8. Which best describes you?

Family physician

Family physician with a focused practice (please specify)

Specialty physician (please specify)

Nurse practitioner

Pharmacist

Other health professional (please specify)

Please specify:

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* 1. Full name:

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* 2. Active email address which you regularly check:

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* 3. Your year of birth:

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* 4. Years in practice:

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* 5. You are:

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* 6. Please provide your CPSO, NPAO, OPA (or applicable professional association) number:

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* 7. In which way(s) would you like to participate in the Collaborative Mentoring Networks?Please select all that apply.

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* 8. Which best describes you?

* 7. In which way(s) would you like to participate in the Collaborative Mentoring Networks?
Please select all that apply.