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ECHO Critical Care & Emergency Nurse Well-Being Registration Form

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We welcome you to join ECHO Critical Care & Emergency Nurse Well-Being Program . This program is designed for Critical Care and Emergency Nurses to share and learn about ways to build resilience and wellness through didactic lectures and case-based discussions.

First Name:

* must provide value

Last Name:

* must provide value

Phone Number:

* must provide value

Email Address:

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Are you a Critical Care OR Emergency Nurse working in Ontario?

* must provide value

Yes

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Please note that this program will only be accepting Critical Care and Emergency Nurses practicing in Ontario.

Organization Name:

* must provide value

Organization City:

* must provide value

Organization Postal Code:

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Which LHIN is your organization a part of?

NOTE: If you are unsure, please input your organization's postal code on this website: http://www.lhins.on.ca/

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Central

Central East

Central West

Champlain

Erie St. Clair

Hamilton Niagara Haldimand Brant

Mississauga Halton

North East

North Simcoe Muskoka

North West

South East

South West

Toronto Central (U of T)

Waterloo Wellington

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Are there any topics you would like to see covered in ECHO Critical Care & Emergency Nurse Well-Being?

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Attached below is the ECHO Critical Care & Emergency Nurse Well-Being Statement of Collaboration that outlines certain conditions which must be understood and agreed to in order to participate in this program.

Please review the Statement of Collaboration.

Attachment:ECHO Critical Care & Emergency Nurse Well-Being - Statement of Collaboration.pdf

Carefully review and check to indicate your agreement to the following statements.

ECHO didactics, Q&As, discussions and case presentations do not create or establish a provider-patient client relationship between any hub clinician and a patient/provider/resident whose case is presented.

* must provide value

I agree

I do not agree

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Personal identifying information about patients/clients/providers/residents is not to be shared during ECHO sessions. If this inadvertently occurs, I will follow my own organization's policies and procedures to address the privacy breach.

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I agree

I do not agree

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Recommendations from the Hub do not in any way replace my own diligence and professional expertise with respect to care providers, residents, and/or my patients/clients.

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I agree

I do not agree

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The ECHO team records sessions for educational purposes and occasionally takes photos for promotion.

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I agree to this statement, and give ECHO Critical Care & Emergency Nurse Well-Being permission to share photo(s) of me externally in presentations, reports and promotional materials. I understand my name, profession, and/or organization will not be included with the photo.

I agree to this statement, but I do not wish to have my photo shared externally. I understand any image of me will be blurred in photos used in externally facing presentations, reports, and promotional materials.

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I have read and agree to the terms of the Statement of Collaboration with preferences as indicated above.

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I agree

I do not agree

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Initial Here

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Add signature

Please provide date:

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D-M-Y

Your submission will be reviewed by our operations team and your participation will be confirmed as soon as possible.

After you have received confirmation of your enrollment in the program we will contact you by email and provide details about next steps.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.