We thank you for taking 5 minutes to complete this questionnaire.
 
If you are selected, you will participate, in person or remotely, at 2.5-hour panel meeting with other health professionals, which will take place in Montreal on September 17th from 5:30 to 8 pm. The meeting will be held in English.

You will also be required to sign a declaration of interest form and a confidentiality form.

If you would like to participate in person and live within a short distance (250 km) from downtown Montreal, your transportation expenses will be reimbursed. A meal will be served at the meeting.

Please be assured that your information will be treated in strict confidence in accordance with applicable laws. None of this information will be made public or shared. The answers you provide will only be used for selecting patients to for the panel regarding oral immunotherapy.

If you need more information, you can contact Marjo Cellier by email (marjo.s.cellier@gmail.com).
YOUR PROFESSIONNAL CONTEXT

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1. Are you a:

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2. What is your interest in participating at this consultation?

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3. Please indicate the food allergies of the patients in whose care you have been or are currently involved. You can check multiple foods.

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4. How would you rate the average severity of these patients’ food allergies?

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5. Have you ever been involved in the care of patients who were receiving oral immunotherapy for their food allergy?

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6. Please provide your professional degree(s)

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7. In which year have you received your professional certification?

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8. In which province/territory do you practice?

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9. In which community (city, town) do you practice?

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10. In which setting do you practice (you can choose multiple responses)?

YOUR PERSONAL CONTEXT

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11. Please provide your contact information:

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12. What is your gender?

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13. What is your age?

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14. The meeting will be held on September 17th, 2019, in downtown Montreal from 5:30 to 8 pm. Will you be available to participate:

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15. During the meeting, we will discuss oral immunotherapy to treat food allergies. Are you comfortable to speak about this subject in English?

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16. What is your opinion on oral immunotherapy? Please indicate how much you agree with the following statements:

  Agree very much Agree Disagree Disagree very much
It seems to me that oral immunotherapy provides important benefits over a strategy of strict avoidance of allergenic foods.
It seems to me that oral immunotherapy provides no benefit compared to a strategy of strict avoidance of allergenic foods.
CONFLICTS OF INTEREST

In accordance with CSACI’s policy on conflicts of interest, we would like to ask you to complete this declaration. A conflict of interest arises when a person finds himself or herself in a situation where, objectively, his or her judgment in a specific situation is likely to be or appears to be influenced by other considerations, whether personal, financial or related to professional activities (e.g., donation, financing, support from the manufacturer of a treatment).

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17. Do you have any conflicts of interest to declare that have occurred in the last two years? This information is not used to reject questionnaires or information provided but to properly manage conflict of interests and roles when they arise.

If yes, indicate the nature of the conflict, the manufacturer or organization involved and the amounts involved, if applicable. This should include any organization directly or indirectly concerned by oral immunotherapy.

For example:

- Personal benefits, for you or a relative, received from a manufacturer or an organization interested in oral immunotherapy (donation, gifts, promotional items, travel, services, shares, stock options, etc.)

- Activities financed by a manufacturer or organization interested in oral immunotherapy (conference participation or organization, committee, research or educational grant, honorarium or salary, etc.)

- Personal or business relationships with a manufacturer or other interest groups, or an employee.

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