The code block below illustrates how one might use # and // as comments in your logic and calculations.

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7qb4bqENeZN2Y8aRL3ZtSZWumPSCr7nwBSHoGmWQAinFZHob7mTICaoSwHUK5f9fcr8dDuGzHZuxR4FtAo4dixIvUkUB95aNk8aibbiIpcwNpNFtImT5gDnXNMG

ECHO Nurse Wellbeing Pop-Up Registration Form: Advocating for Change from a Systems Perspective (February 17, 2023)

The ECHO Ontario Nurse Wellbeing pop-up session on the topic of "Advocating for Change from a Systems Perspective" will take place from 2:00 PM - 3:00 PM EST on Friday, February 17, 2023

If you are interested in attending this ECHO Ontario CCENWB pop-up session, please complete the short application below. We will be in touch to confirm your participation.

First Name:

* must provide value

Last Name:

* must provide value

Email Address:

* must provide value

Phone Number:

* must provide value

Extension (if applicable):

Alternative Phone Number:

Name of Organization:

* must provide value

Organization Address:

* must provide value

Organization City:

* must provide value

Organization Postal Code:

* must provide value

What is your primary profession? Select all that apply.

* must provide value

Registered Nurse

Nurse Practitioner

Registered Practical Nurse

Other

Please specify:

* must provide value

Please indicate your primary practice setting:

* must provide value

Private Practice / Solo Practitioner

Family Health Team

Family Health Organization

Family Health Group

Community Health Centre

Community Health Agency

Nurse Practitioner-led Clinic

University/College Health Care Centre

Residency

Academic Hospital

Other

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Please specify:

* must provide value

Which LHIN are you a part of?

* must provide value

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

Waterloo Wellington

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Have you participated in an ECHO Ontario Mental Health program before?

* must provide value

Yes

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Attached below is the ECHO ONMH Confidentiality & Data Use Agreement that outlines certain conditions which must be understood and agreed to in order to participate in an ECHO pop-up session.

Please review the ECHO Confidentiality & Data Use Agreement attached.

Attachment:ECHO Critical Care & Emergency Nurse Well-Being - Statement of Collaboration - Pop Up Session - Feb 17 2023.pdf

My participation data will be shared with the Ministry of Health, ECHO Ontario Superhub, and the Project ECHO Institute at the University of New Mexico as outlined in the Confidentiality & Data Use Agreement

* must provide value

I agree

I agree to have my data shared with the Ministry of Health, ECHO Ontario Superhub, and the Project ECHO Institute at the University of New Mexico

I've read the Confidentiality & Data Use Agreement, but have questions. Please contact me to discuss.

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I have read and agree to the terms of the Confidentiality & Data Use Agreement.

* must provide value

I agree Please contact me

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Initial Here

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Add signature

Please provide date:

* must provide value

D-M-Y

Please select 'Submit' in order to submit your application.

After you have received confirmation of your enrollment in the program we will contact you 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.