CoNO Registrant Support

Data Collection for Therapeutic Prescribing

Dear Registrant,


You have enrolled in the CoNO Support process for data collection relating to therapeutic prescribing. This form is unique to you and the URL provided to access it is unique to you. Please do not give it out to anyone else. It is used for the next year to allow you to submit your data for tabulation and later reporting to the College.


You can use this form on the frequency that you determine. At the end of the year, the College will automatically send the data collected over the year to you using an automated process. You can then formally submit the data to the College on the required form.


PLEASE NOTE: The College will not automatically take the data from this process over to the formal reporting process. This allows for registrants to check the quality of the data.

REGISTRANT INFORMATION

This form is for the exclusive use of:


Dr. Jane Doe, ND

Registrant No.:

Email address:

Since your last report, and only for the purposes of this data submission, please indicate the controlled acts related to the Standard of Practice for Therapeutic Prescribing which you have performed in any of your practice locations.

PRESCRIBING, DISPENSING, COMPOUNDING AND SELLING DRUGS

The following questions related to the controlled acts of prescribing, dispensing, compounding and selling drugs. It is not anticipated that a Registrant would do all of these controlled act or do so in the same volume.

Of the total number of patients to whom you have prescribed, dispensed, compounded or sold drugs, in total how many times has an adverse occurrence resulted? This is a required question. If you have had no adverse occurrences, please enter 0.


An adverse occurrence is any of

  • Referral to emergency services within 5 days
  • Administering emergency drug
  • Diagnosis of shock or convulsions within 5 days
  • Condition did not improve or worsened
  • Unscheduled treatments
  • Adverse reactions

Of the patients to whom you have prescribed, dispensed, compounded and sold drugs, which of the following adverse occurrences have been experienced in your practice. Please select all that apply.

You have identified that one or more of your patients has encountered an adverse reaction to a drug that you have prescribed, dispensed, compounded or sold. Please identify the types of adverse reactions encountered. Please select all that apply.

ADMINISTERING SUBSTANCES BY INJECTION

The following questions related to the controlled act of administering a substance by injection.

Please indicate the total number of administrations of a substance by injection that you have performed in all of your practice locations in this reporting period.

Of the total number of administration of substances by injection, in total how many times has an adverse occurrence resulted? This is a required question. If you have had no adverse occurrences, please enter 0.


An adverse occurrence is any of

  • Referral to emergency services within 5 days
  • Administering emergency drug
  • Diagnosis of shock or convulsions within 5 days
  • Condition did not improve or worsened
  • Infection
  • Unscheduled treatments
  • Adverse reactions

Of the patients to whom you have administered a substance by injection, which of the following adverse occurrences have been experienced in your practice. Please select all that apply.

Please indicate the types of infections that your patients have encountered in your practice after you have administered a substance by injection. Select all that apply.

Please indicate the types of conditions that you have had to treat for your patients after you have administered a substance by injection. Select all that apply.

Please indicate the types of adverse reactions that your patients have encountered in your practice after you have administered a substance by injection. Select all that apply.

ADMINISTERING SUBSTANCES BY INHALATION

Please indicate the total number of administrations of a substance by inhalation you have performed in all of your practice locations in this reporting period.

Of the total number of administrations by inhalation you have performed, in total how many times has an adverse occurrence resulted? This is a required question. If you have had no adverse occurrences, please enter 0.


An adverse occurrence is any of

  • Referral to emergency services within 5 days
  • Administering emergency drug
  • Diagnosis of shock or convulsions within 5 days
  • Condition did not improve or worsened
  • Infection
  • Unscheduled treatments
  • Adverse reactions

Of the patients to whom you have administered a substance by inhalation, which of the following adverse occurrences have been experienced in your practice. Please select all that apply.

Please indicate the types of infections that your patients have encountered in your practice after you have administered a substance by inhalation. Select all that apply.

Please indicate the types of conditions that you have had to treat for your patients after you have administered a substance by inhalation. Select all that apply.

Please indicate the types of adverse reactions that your patients have encountered in your practice after you have administered a substance by inhalation. Select all that apply.

Copy of your submission

Although the College will send you a summary of the data that you have submitted at the end of the calendar year, it is recommended that you check the box below to receive a copy of your submission for your own records.


To receive a copy, check this box and enter your e-mail address. This will enable the on-line system to send you a copy of the information that you have provided to the College.


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