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Lead Toolkit Registration Form
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
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3.
Email Address
(Required.)
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4.
Practice Name
(Required.)
5.
Practice Address
Street
City
Zip Code
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6.
What is your credential?
(Required.)
MD
DO
DNP
NP
PA
Other (please specify)
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7.
What is your specialty?
(Required.)
General Pediatrics
Family Medicine
Other (please specify)
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8.
Which of the following is the best description of your practice?
(Required.)
Solo practice
Group practice
Hospital-owned
Federally Qualified Health Center (FQHC)
Academic Health Center
Other (please specify)
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9.
Have you participated in an Ohio AAP Childhood Lead Prevention Training or QI Project?
(Required.)
Yes, I have participated in a training
Yes, I have participated in the QI project
No
Other (please specify)
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10.
How did you learn about the toolkit? (Select all that apply)
(Required.)
Ohio AAP Today newsletter
Personal email from Ohio AAP
Personal phone call from Ohio AAP
Other Ohio AAP email
Ohio AAP Annual Meeting
Ohio AAP live webinar/training
Ohio AAP Facebook
Ohio AAP Instagram
Ohio AAP Twitter
Ohio AAP LinkedIn
Word of mouth (e.g., colleague, friend, patient/family)
Other (please specify)
11.
How confident are you in providing lead anticipatory guidance and resources?
Extremely confident
Very confident
Somewhat confident
Not so confident
Not at all confident
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12.
What are your top 1-2 reasons for requesting the Lead toolkit?
(Required.)