MISUD May 2018 La1

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Required format:

niNnupS94u7BTPwIaG4bsQbS6sIumDZp6bIto3LaHCdRihjfmTbQ9VcYCXbRbI5RP2LgoQN88ioJB7pfhUEbEiqfkSBjEPYD3Xn

Course Registration and Pre-Learning Assessment

Tobacco Interventions for Clients with Mental Illness and/or Substance Use Disorders

(Specialty Course)

May 23 - June 27, 2018

Online

Please take a few moments to fill out this assessment before the 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 May 18, 2018

First Name:

* must provide value

Last Name:

* must provide value

E-mail address:

* must provide value

Confirm E-mail address:

* must provide value

Organization/Agency Name:

* must provide value

Organization Address:

* must provide value

City:

* must provide value

Province:

* must provide value

Postal/Zip Code:

* must provide value

Business/Work Phone Number:

* must provide value

Home Address:

* must provide value

City:

* must provide value

Province:

* must provide value

Postal/Zip Code

* must provide value

Home Phone Number:

* must provide value

Mobile/Cell Phone Number:

* must provide value

Primary Contact Number:

* must provide value

Same as Business Phone Number

Same as Home Phone Number

Same as Mobile/Cell Phone Number

Other/s

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* must provide value

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?

* must provide value

Please indicate if you work for a/an:

* must provide value

What is your current discipline?

* must provide value

What region does your organization serve?

* must provide value

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:

* must provide value

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?

* must provide value

Yes

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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.