Core Sept 2018 La1

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Course Registration and Pre-Learning Assessment

An Interprofessional Comprehensive Course on Treating Tobacco Use Disorder

(Core Course)

September 26 - October 31, 2018

Online

Please take a few moments to fill out this assessment before the Core Course begins. You must enter your responses to this learning assessment prior to completing the course as per accreditation requirements. This assessment is required in order to complete the course and, if applicable, to be eligible to receive a Certificate in Intensive Cessation Counselling from the University of Toronto, Faculty of Medicine, Department of Continuing Education.

We are interested in getting an understanding of the impact this course will have on your work with your clients. This information will also help guide future course development and help us to evaluate your pre and post ratings of key concepts.

DUE DATE: Friday September 21, 2018

First Name:

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Last Name:

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E-mail address:

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Confirm E-mail address:

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Organization/Agency Name:

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Organization Address:

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City:

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Province:

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Postal/Zip Code:

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Business/Work Phone Number:

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Home Address:

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City:

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Province:

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Postal/Zip Code

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Home Phone Number:

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Mobile/Cell Phone Number:

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Primary Contact Number:

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Same as Business Phone Number

Same as Home Phone Number

Same as Mobile/Cell Phone Number

Other/s

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Please note that the next two questions regarding age and gender are optional and are asked for the purposes of program evaluation and reporting only. Declining to answer any of the following questions regarding age and gender will not impact the application selection process in any way.

Please identify your sex:

Age:

30 or under

31 - 40

41 - 50

51 - 60

Over 60

Prefer not to answer

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In which sector do you primarily work?

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Please indicate if you work for a/an:

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What is your current discipline?

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What region does your organization serve?

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To help facilitate the development of partnerships and resources in your community, TEACH would like to share your contact information with your local Tobacco Control Area Network (TCAN) Coordinator, CAMH Consultant and with Smokers' Helpline Ontario. Your contact information will not be shared with any other agencies or individuals.

Please indicate which of the following organizations that you would like your contact information to be shared with:

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Tobacco Control Area Network (TCAN) Coordinator

CAMH Regional Consultant

Smoker's Helpine Ontario

Do not share my information

Would you like to join the TEACH mailing list and be informed of upcoming trainings, initiatives, and other opportunities related to the TEACH Project?

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Yes

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