Register for Professional Development in Communication and Supportive Care (PDCSC) 2023-2024

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oKzDNEk9meeUnRSJThbqqkak6vZK66bKCiDNVqgDsYv99GkNRGPg4kxx4ZWeXL9k2QuNR24pHkHaC4NCsQ36wEQRruPkQiaTXwugsVE5XDbhtG

Thank you for your interest in the PDCSC. This course offers sessions on palliative care across the lifespan for adults, pediatrics, and geriatrics and vulnerable patient populations. Many sessions are presented by interdisciplinary providers for an interdisciplinary perspective on care.

We encourage participants to select the topics that meet their learning needs. You will not be able to attend all of the sessions offered.

That said, we encourage you to save the dates to attend -

1) A full-day communication skills conference in-person on 9/29* or on Zoom on 9/30.

2) A half-day communication skills workshop with simulated patients on 11/17 - virtually.

*Held at the Morton Arboretum in Lisle, Illinois and repeated on 9/30 for those unable to travel.

Attending live webinars is recommneded to participate in Q & A. Webinar recordings will be availalbe on a learning management system.

Additionally, social workers, psychologists and chaplains attend 3 half-day seminars virtually.

The expected time commitment is between 4 to 8 hours per month.

Some participants discuss the time commitment with their supervisor. You may refer to this form: Supervisor Endorsement Statement (click to download)

Payment is not collected here. After you submit this registration form, you will receive an email with payment instructions. Receipt of payment will secure your spot in this course. Spaces are limited, and will fill on a first come, first served basis.

If you have any questions, please contact Aliza Baron at abaron@uchicago.edu.

First name

Last name

Street Address

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City

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State (if residing outside the US, please include country)

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Zip code (or country code if outside the US)

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Year of Birth

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Phone Number

Email Address

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Alternate Email Address

Profession

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Advanced Practice Nurse

Social Worker

Chaplain

Physician

Physician Assistant

Nurse

Psychologist

Other

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Other Profession

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Credentials/degrees (to appear on a certificate of course completion)

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Employer

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Employment address: City, state, and country

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Are you an alumni of the Professional Development in Communication Skills (PDCSC) course in 2020 or 2021, or a former "Coleman Fellow" from 2015 or 2017?

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Yes

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Alumni are eligible for a 50% off discount this year. Please do not pay for the course until you receive the discount code from Aliza Baron abaron@uchicago.edu

What type of organization do you work for?

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Academic medical center/research institution

Community based health care organization

Safety net hospital

Government facility (e.g. Veterans Association)

FQHC

Other

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FQHC staff are eligible for a 50% off scholarship. You will receive a scholarship code after registering from Aliza Baron abaron@uchicago.edu.
Thank you.

Please explain

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Which location most accurately describes your practice setting?

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Urban

Suburban

Rural

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Do you currently have access to palliative medicine services for your patients?

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Yes

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Please describe.

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Job title

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What is your employment status?

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Please describe.

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What practice settings do you work in?

Please check all that apply.

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Inpatient setting

Ambulatory or clinic setting

Home health care

Hospice

Nursing home

Other

Please describe your practice setting.

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What patient populations do you care for? Check ALL that apply.

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Older adults, 65 yrs and older

Adults

Adolescent and young adults

Pediatrics

Other

What percent of your patients are pediatrics? adolescents? and young adults?
Please list each.

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Please describe.

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Please describe your current practice.

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Please describe your experience working with complex, seriously ill patients.

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Do you work in a palliative care position, and if so, for how long?

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I do not work in a palliative care position

Less than 6 months

6 months - 1 year

1 - 2 years

2- 4 years

4 - 6 years

> 6 years

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Have you had any prior palliative care training?

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Yes

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Please describe the prior palliative care training.

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What palliative care or supportive care skills are you aiming to develop?

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Optional:
Please briefly describe a difficult patient case or work experience. We will try to use your cases as examples during the course. Do not include any information that may identify the patient, yourself, colleagues, supervisors or health care organizations.

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A full-day communication skills conference offered in-person and virtually.
Do you prefer to attend in-person at the Morton Arboretum in Lisle, Illinois on Fri., 9/29 or virtually on Sat., 9/30?

The conference agenda will be the same, and communication skill role plays will take place in-person and virtually.

* must provide value

In-person on Fri. 9/29 at the Morton Arboretum, Lisle, IL

Virtually on Sat., 9/30

Undecided, I will contact Aliza Baron by 9/16.

I am not able to attend this conference.

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Physicians, advance practice nurses, physician assistants and nurses who aspire to work in palliative care or currently work in palliative care are invited to add-on the Specialty-Level Palliative Care Webinars Series.

11 live webinars held weekly from mid-March to late May and recorded for viewing on your schedule.
12 CME/CE credits are available.
April - June 2024

Are you interested in this optional add-on?

Topics include:

Cardiac Palliative Care

Palliative Care for Persons Living with CNS Tumors

Methadone and Its Role as an Analgesic in Serious Illnesses

Oncology for Palliative Care Providers

Neurodegenerative Diseases and Neuropsychiatric Symptoms

Documentation and Billing in Palliative Care

Pain Cases in Palliative Care

Consult Etiquette in Palliative Care

Interventional Pain Service

Buprenorphine for Chronic Pain and Opioid Use Disorder, Part I

Buprenorphine for Chronic Pain and Opioid Use Disorder, Part II

Additional Course Fee:

Physician	$390
Advanced Practice Nurse	$312
Physician Assistant	$312
Nurse	$195

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Yes

Undecided

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COMMITMENT STATEMENT

Spaces are limited in this course. We ask that you commit to attending the virtual educational sessions or viewing session recordings.

I also understand that CME/CE credits are earned by attendance and completing evaluations of each session.

Please type your initials here.

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How did you hear about the Coleman Palliative Medicine Training Program?

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After submitting this form, you will receive an email with instructions on how to submit your course payment onilne or by mailing a check.

If you work at a FQHC, a safety net site or a rural site without access to palliative care, you may be eligible for a scholarship. Tell us more in the question at the end, or contact Aliza Baron at abaron@uchicago.edu.

Who will be paying for this course?

Self-pay

Employer pays

Do not know

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Will the payment be made by check or credit card?

Check

Credit card

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If there is any other information that you would like to include, please add it here.

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