Clinician-Patient Communication (CPC) Workshop Application Form
This application form is estimated to require 10 minutes to complete.
**All fields are required. Please enter N/A if "Not Applicable."
Part I:
Host Organization/Institution Information
What is the purpose for requesting an AAOS sponsored Clinician-Patient Communication workshop at your organization/institution?
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Is your organization/institution considered
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Please Select
an Orthopaedic Residency Program
a State Orthopaedic Society
an Orthopaedic Specialty Society
Other
Name of Organization/Institution:
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Location: (Address, City, State, and Postal Code)
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Orthopaedic Residency Program Director's Name, Email & Phone Number:
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Orthopaedic Residency Program Chair's Name, Email & Phone Number:
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Orthopaedic Residency Program Coordinator's Name, Email & Phone Number:
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State Orthopaedic Society President's Name, Email & Phone Number:
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State Orthopaedic Society Executive Director's Name, Email & Phone Number: (If there are 2 Executive Directors, please provide the names and contact information of both)
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Orthopaedic Specialty Society President's Name, Email & Phone Number:
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Orthopaedic Specialty Society Executive Director"s Name, Email & Phone Number: (If there are 2 Executive Directors, please provide the names and contact information of both)
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Name, Email & Phone Number of Primary/Main Contact for Scheduling a CPC Workshop:
*
Part II: Communication Skills Training
Has your organization/institution provided training in communication skills?
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Please Select
Yes
No
If you answered "yes," what type of communication skills training was conducted?
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Please Select
An AAOS provided Communication Skills Mentoring Program workshop
Other
If the training was an AAOS provided the CPC workshop, what is the most recent date of the last workshop presented at your organization/institution?
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-
Month
-
Day
Year
Date
If your organization/institution provided a different form of communication skills training, please describe the type of training that was conducted.
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When is your next RRC review? (Only applicable to Orthopaedic Residency Programs)
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-
Month
-
Day
Year
Date
What are your expectations for hosting an AAOS provided CPC workshop?
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If a CPC workshop is held at your organization/institution, what is your plan for ongoing communication skills training and implementation?
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Part III: Workshop Scheduling Information
How many workshops would your organization/institution like to host?
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Please Select
1 workshop
2 workshops
More than 2 workshops
Other
When would your organization/institution like to host a CPC(s) workshop? (Please indicate up to 4 potential date options and number them in order of preference (Date Option #1- Date Option #4))
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What time would you like to host an AAOS provided CPC workshop(s)
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Please Select
Morning (8 am - 12 pm)
Afternoon (12 pm - 4 pm)
Evening (4 pm - 8pm)
Who is the CPC workshop for?
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Please Select
Orthopaedic Residents
Faculty
Orthopaedic Surgeons in Practice
Other
Approximately how many participants do you anticipate attending each CPC workshop?
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Please Select
Less than 20 participants
20-25 participants
More than 25 participants
Other
Part IV: Additional Information
If AAOS should have any questions regarding this application form, what is the applicant"s name and contact information?
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Other Questions/Comments:
Submit
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