The information collected here will only be used for registration purposes and data collection on the types of health professionals taking the TEACH course. All data will be aggregated and anonymous.
Registration Form
Name:Organization:
Address:
City: / Postal Code:
Email:
Telephone: ( ) / Fax: ( )
Do you work for a PCN/Health Region/Office:
Number of years practicing:
Experience with providing tobacco cessation intervention (# of years):
What percent of your work time is spent in direct clinical contact with patients/clients (place an X):
0 – 25% 26 – 50% 51 – 75% 76 – 100%
Average number of patients per day:
What discipline do you belong to (place an X):
General practitioners and family physiciansSpecialist physicians
Registered nurses
Licensed practical nurses
Respiratory therapists and asthma educators
Pharmacists
Dieticians and Nutritionists
Social workers
Psychologists / Chiropractors
Physiotherapists
Occupational Therapists
Midwives and practitioners of natural healing
Dental Hygienist and Assistants
Dentist
Other (please specify):
What special populations do you currently work with: (“X” all that apply)
Pregnant clientsConcurrent disorders (MH and/or addiction)
Older adults
Youth
LGBTTTIQ (Lesbian, Gay, Bisexual, Transgender, Transsexual, Two-Sprit, Intersex, Queer communities) / Differently abled
Aboriginal
Low Income
Culture specific, please identify
Others, please specify
Have you received previous smoking cessation training from TEACH, University of Massachusetts or Mayo Clinic?
No Yes
If yes, please provide details:
Name of training provider (organization):
Date(s) of training:
Name of course(s)/workshop(s):
Certificate of completion received? No Yes
Are you currently – or do you plan on - offering intensive tobacco cessation counselling (defined as longer than 10 minute sessions) to clients in your agency/program? (Check all that apply)
Yes, group sessions
Yes, intensive individual sessions (longer than 10 minute sessions)
No, but I plan to offer intensive individual sessions after receiving TEACH training
No, but I plan to begin offering a cessation group after receiving TEACH training
No cessation interventions offered at present, and no plans to offer intensive individual or group cessation interventions
No, but I offer brief tobacco interventions (less than 10 minute sessions)
No, but I plan to begin offering brief tobacco interventions (less than 10 minute sessions)
Other (please specify) ______
Where did you hear about the TEACH project:
Flyer
Colleague
Web posting
Direct contact with ACB team
List serv, or bulletin board on internet
other, please specify: ______