Describe your case and your main question you would like addressed by the ECHO participants.
Note: If you do not have information for a category, just insert "unknown", "not applicable (NA)" to move to next question.
Do not include any Protected Health Information (PHI).
You may email PHI free documents to Midwest.Tribal.Echo@hcmed.org or Fax attn: Michelle Corcoran to 612-872-8547.
By submitting this survey you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between any ECHO clinician and any patient whose case is being presented in a teleECHO clinic.