Registration form (Dryden) Register here for the CAMAP MAID training event in Dryden. Thursday, April 16, 2020 1:00 - 5:00 PM Name*ProfessionFamily physician/GPNurse practitionerMedical specialistRNAllied healthOtherPlease specifyMedical specialtyRegulatory college numberEmail* Phone*Please indicate any dietary restrictionsPre-test and needs assessmentHow 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.Which of the following barriers do you anticipate in providing MAID? Select All 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?DemographicsAgeUnder 3030-3940-4950-5960+GenderFemaleMaleOtherWas your medical training done in Canada?YesNoHow many years have you been in practice?Less than 1 year1-5 years6-15 yearsOver 15 yearsMedical resident/NP studentWhat is the population of your community?<25,00025,000 - 250,000250,000 - 500,000Over 500,000
