Osteoporosis Canada - Fracture Liaison Service | FLS Renewal OOS sites | Osteoporosis Canada

OOS (individual) FLS Renewal Form

Step 1 of 5

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Section 1: Information about your FLS
Within OC’s FLS Registry, FLSs are assessed by individual hospital sites. For hospital corporations which may operate an FLS at two or more separate sites, a separate submission form must be filled out for each individual FLS site. For any questions in filling out this questionnaire, please contact Luanne Schenkels at lschenkels@osteoporosis.ca
FLS site information
Person submitting this form:
First name Last name
Email of submitter
1. Name of your hospital/site, exactly as it should appear on the OC FLS Registry:
Address of FLS site
Street Address Address Line 2 City Province Postal Code

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Section 2: Staff working for your FLS
2. a. Dedicated FLS coordinator’s name:
First Last
FTE's at this site:
2. b. Educational background of the FLS coordinator:
- i) RN
- ii) NP
- iii) RPN/LPN
- iv) Other
Other, please specify:
2. c. Has the FLS coordinator been absent from the FLS (e.g. medical leave) for more than 6 consecutive months in the last year?
- Yes
- No
If yes, please provide details regarding the duration of the absence (please provide a start date and end (or anticipated) date of absence. PLEASE NOTE: Do not provide details regarding the reason for the absence.
2. d. Is there more than one FLS Coordinator working at your site?
- No
- Yes, there is one additional FLS Coordinator working at our site.
- Yes, there are more than 2 FLS Coordinators working at our site. Please provide details in the comments section.
Comments (name of additional FLS Coordinators, FTEs, educational background and if on leave for longer than 6 consecutive months) in the last year:
a.i. Dedicated FLS coordinator’s name:
First Last
FTE's at this site:
Educational background of the FLS coordinator:
- i) RN
- ii) NP
- iii) RPN/LPN
- iv) Other
Other, please specify:
Has the FLS coordinator been absent from the FLS (e.g. medical leave) for more than 6 consecutive months in the last year?
- Yes
- No
If yes, please provide details:

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Section 3: Type of FLS
3. a. Type of FLS:
(Click only one answer)
- a. Outpatient-only FLS (i.e. the FLS coordinator first meets the patient directly in the orthopaedic outpatient clinics).
- b. Combined inpatient/outpatient FLS (i.e. the FLS coordinator does systematic and pro-active case finding both on the orthopaedic inpatient ward AND in the orthopaedic outpatient clinics. Some patients, e.g. hip fracture patients, are first seen in person while still on the orthopaedic ward and others, e.g. wrist fracture patients, are first seen in person during their visit to the orthopaedic outpatient clinic).
- c. Other.
If other, please describe:
Please specify when orthopaedic clinics are held in your hospital.
(Click all that apply)
- Monday morning
- Monday afternoon
- Tuesday morning
- Tuesday afternoon
- Wednesday morning
- Wednesday afternoon
- Thursday morning
- Thursday afternoon
- Friday morning
- Friday afternoon
- Saturday morning
- Saturday afternoon
- Sunday morning
- Sunday afternoon
Please specify which orthopaedic clinics are attended by your FLS coordinator (in a typical week).
(Click all that apply)
- Monday morning
- Monday afternoon
- Tuesday morning
- Tuesday afternoon
- Wednesday morning
- Wednesday afternoon
- Thursday morning
- Thursday afternoon
- Friday morning
- Friday afternoon
- Saturday morning
- Saturday afternoon
- Sunday morning
- Sunday afternoon
Please specify when orthopaedic clinics are held in your hospital.
(Click all that apply)
- Monday morning
- Monday afternoon
- Tuesday morning
- Tuesday afternoon
- Wednesday morning
- Wednesday afternoon
- Thursday morning
- Thursday afternoon
- Friday morning
- Friday afternoon
- Saturday morning
- Saturday afternoon
- Sunday morning
- Sunday afternoon
Please specify which orthopaedic clinics are attended by your FLS coordinator (in a typical week).
(Click all that apply)
- Monday morning
- Monday afternoon
- Tuesday morning
- Tuesday afternoon
- Wednesday morning
- Wednesday afternoon
- Thursday morning
- Thursday afternoon
- Friday morning
- Friday afternoon
- Saturday morning
- Saturday afternoon
- Sunday morning
- Sunday afternoon

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Section 4: Enrollment data
4. a. Number of hip fracture patients admitted annually to your hospital as per hospital's independent administrative database (12 month period: please specify start and end dates):
4. b. Total number of fragility fracture patients (aged 50 and up) who were newly enrolled in your FLS in the last year(12 month period: please specify start and end dates):
4. c. Of the patients in "b" (above), how many were hip (proximal femur) fractures?

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Section 5: Permission
Thank you for your collaboration.*
Osteoporosis Canada may use aggregate data from this audit for possible publication and/or research purposes. The individual FLS sites would remain completely anonymous in the event of any publication.
- I consent to the use of the data collected in this questionnaire for the purpose stated above.
- I do not consent to the use of the data collected in this questionnaire for the purpose stated above.

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FLS Renewal OOS sites

OOS (individual) FLS Renewal Form

Step 1 of 5

Section 1: Information about your FLS

FLS site information

Section 2: Staff working for your FLS

Section 3: Type of FLS

Section 4: Enrollment data

Section 5: Permission