[ADD PREFILLED INFO HERE]

LARGE URBAN POPULATION CENTRES (INNER-CITY): High population density area (>400 person per square kilometre) with a population of >500,000.

LARGE URBAN POPULATION CENTRES (SUBURBAN): High population density area (>400 person per square kilometre) with a population of >500,000.

MEDIUM POPULATION CENTRES: High population density area (>400 person per square kilometre) with a population of >30,000 and <500,000.

SMALL POPULATION CENTRES:  Population density of at least 400 persons per square kilometre and a population between 1,000 and 29,999. 

RURAL AND REMOTE AREAS:  Any territory lying outside of small population centres with low population density (<400 persons per square kilometre).

[INSERT INFO HERE]

[INSERT PREFILLED INFO HERE]

In your opinion, what percentage of long-term care facilities in your region integrate palliative care (e.g. have a palliative care strategy, train staff in the palliative care approach, refer to palliative care services)? 

This survey is part of the Canadian Atlas of Palliative Care - Pilot Study project. The research team is lead by Dr. José Pereira of the Department of Family Medicine at McMaster University and Pallium Canada, and Dr. Michelle Howard of the Department of Family Medicine at McMaster University. The purpose of the survey is to explore and report the status of palliative care in your region across several domains. Information gathered during this survey will be part of a larger Canadian Atlas of Palliative Care. The Atlas will provide a graphical (using maps and graphs) and verbal (text) representation and description of the current state of palliative care in a jurisdiction (e.g., (health) region, province/territory, nationally). It will explore the state of palliative care across several domains. These include, amongst others, funding for and availability of palliative care services, policies and formal strategic plans in health services planning related to palliative care, and education. The hope is that the Atlas will serve to highlight excellence across the country, identify gaps, and become an advocacy tool as well as a guide to policymakers and funders. For an example of the Atlas approach, please see the Atlas of Palliative Care in Europe (2019).

To learn more about this survey and the study, please see the Information Sheet sent with the invitation to participate. This sheet contains information about anticipated risks and harms, how confidentiality and anonymity will be handled, withdrawal procedures, how to obtain information about the survey’s results, secondary use of data, and how to find helpful resources if you experience discomfort about completing it.

As a Pallium Learning Essential Approaches to Palliative Care (LEAP) facilitator and/or subject matter expert in the palliative care realm, you are very familiar with palliative care service provision in your region. To assist with some of the questions, we have prefilled some information (such as a list of hospitals and residential hospices with number of beds in your region). This information was retrieved from publicly available sources (e.g., websites). Please review this information and verify for accuracy. We encourage you to obtain input from other persons in your region who may have some of the information being requested in this survey. You may also skip questions that are not applicable or for which you don’t have information about.

If you wish, you can save your answers and return to the survey at a later time via the “Save” button. Once you finish the survey, please complete your submission by clicking “Submit”. Please note that the window to complete the survey is three weeks; up to two reminders will be sent.

This survey is divided into 4 Parts: 1. Introduction, 2. About You, 3. Domains/Elements and 4. Submission. It should take approximately 15 to 60 minutes to complete, depending on the specific palliative care activities in your region.

The project is first undertaking a pilot in two (former) Ontario health regions. This pilot has been reviewed and cleared by the Hamilton Integrated Research Ethics Board (HiREB). The protocol number associated with this research is [number to be added here upon approval].

Your participation in this research study is entirely voluntary. You may refuse to answer any questions and are free to skip to other sections of the survey or quit survey participation at any time. There are no known or anticipated risks to participating in this survey.

If you have any questions or would like more information about the Canadian Atlas of Palliative Care - Pilot Study itself, please contact the research team via Pallium Canada at (613) 562-6262, extension 1784.

If you have any questions about your rights as a research participant, please contact the Office of the Chair, Hamilton Integrated Research Ethics Board (HiREB) at (905) 521-2100, extension 42013.

The project is funded by Pallium Canada, a national, non profit evidence-based organization focused on building professional and community capacity to help improve the quality and accessibility of palliative care in Canada. For further information please visit: http://www.pallium.ca.

Consent to Participate

I have read the preceding information thoroughly. I have had an opportunity to ask questions and all of my questions have been answered to my satisfaction. I agree to participate in this study under the terms and conditions outlined in the Information Sheet. I understand that I can print a copy of this form for my files.

This survey is part of the Canadian Atlas of Palliative Care - Pilot Study project. The research team is lead by Dr. José Pereira of the Department of Family Medicine at McMaster University and Pallium Canada, and Dr. Michelle Howard of the Department of Family Medicine at McMaster University. The purpose of the survey is to explore and report the status of palliative care in your region across several domains. Information gathered during this survey will be part of a larger Canadian Atlas of Palliative Care. The Atlas will provide a graphical (using maps and graphs) and verbal (text) representation and description of the current state of palliative care in a jurisdiction (e.g., (health) region, province/territory, nationally). It will explore the state of palliative care across several domains. These include, amongst others, funding for and availability of palliative care services, policies and formal strategic plans in health services planning related to palliative care, and education. The hope is that the Atlas will serve to highlight excellence across the country, identify gaps, and become an advocacy tool as well as a guide to policymakers and funders. For an example of the Atlas approach, please see the Atlas of Palliative Care in Europe (2019).

To learn more about this survey and the study, please see the Information Sheet sent with the invitation to participate. This sheet contains information about anticipated risks and harms, how confidentiality and anonymity will be handled, withdrawal procedures, how to obtain information about the survey’s results, secondary use of data, and how to find helpful resources if you experience discomfort about completing it.

As a Pallium Learning Essential Approaches to Palliative Care (LEAP) facilitator and/or subject matter expert in the palliative care realm, you are very familiar with palliative care service provision in your region. To assist with some of the questions, we have prefilled some information (such as a list of hospitals and residential hospices with number of beds in your region). This information was retrieved from publicly available sources (e.g., websites). Please review this information and verify for accuracy. We encourage you to obtain input from other persons in your region who may have some of the information being requested in this survey. You may also skip questions that are not applicable or for which you don’t have information about.

If you wish, you can save your answers and return to the survey at a later time via the “Save” button. Once you finish the survey, please complete your submission by clicking “Submit”. Please note that the window to complete the survey is three weeks; up to two reminders will be sent.

This survey is divided into 4 Parts: 1. Introduction, 2. About You, 3. Domains/Elements and 4. Submission. It should take approximately 15 to 60 minutes to complete, depending on the specific palliative care activities in your region.

The project is first undertaking a pilot in two (former) Ontario health regions. This pilot has been reviewed and cleared by the Hamilton Integrated Research Ethics Board (HiREB). The protocol number associated with this research is [number to be added here upon approval].

Your participation in this research study is entirely voluntary. You may refuse to answer any questions and are free to skip to other sections of the survey or quit survey participation at any time. There are no known or anticipated risks to participating in this survey.

If you have any questions or would like more information about the Canadian Atlas of Palliative Care - Pilot Study itself, please contact the research team via Pallium Canada at (613) 562-6262, extension 1784.

If you have any questions about your rights as a research participant, please contact the Office of the Chair, Hamilton Integrated Research Ethics Board (HiREB) at (905) 521-2100, extension 42013.

The project is funded by Pallium Canada, a national, non profit evidence-based organization focused on building professional and community capacity to help improve the quality and accessibility of palliative care in Canada. For further information please visit: http://www.pallium.ca.

Consent to Participate

I have read the preceding information thoroughly. I have had an opportunity to ask questions and all of my questions have been answered to my satisfaction. I agree to participate in this study under the terms and conditions outlined in the Information Sheet. I understand that I can print a copy of this form for my files.