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Registration form for CAMAP MAID Workshop in the NWT on May 4, 2022
Name
*
Profession
Family physician/GP
Nurse practitioner
Medical specialist
RN
Allied health
Other
Please specify
Medical specialty
Regulatory college number
Email
*
Phone
*
City/Community
*
Pre-test and needs assessment
How many MAiD assessments have you performed?
Please enter a number from
0
to
1000
.
How many MAiD provisions have you administered?
Please enter a number from
0
to
1000
.
If you have done either/both assessments or provisions, has your practice changed since the C7 legislation came into effect? If yes, how?
Which of the following barriers do you anticipate in providing MAID?
Knowledge of drugs
Knowledge of the legal requirements and documentation
Communication with colleagues and institutions in your area
Emotional challenges
Time constraints
Lack of remuneration
Please select all that are relevant to you.
Any other barriers not mentioned?
What are you hoping to learn from the workshop?
Demographics
Age
Under 30
30-39
40-49
50-59
60+
Gender
Female
Male
Transgender/two-spirit
Prefer not to say
Other
Was your clinical training done in Canada?
Yes
No
How many years have you been in practice?
Less than 1 year
1-5 years
6-15 years
Over 15 years
Medical resident/NP student
What is the population of your community?
<25,000
25,000 - 250,000
250,000 - 500,000
Over 500,000
