Your Demographic and Contact Information

Thank you for your interest in Project ECHO Ontario: Epilepsy Across the Lifespan! We'd like to learn a little more about you, your interest in Project ECHO, and your practice. The registration form will take 5 minutes or less to complete. If you have registered before but would like to update your information, or if you have concerns or questions, please reach out to Salma Hussein, Administrative Assistant at salma.hussein@sickkids.ca.

Collected information will be used by the project team for the following purposes:
  • Registration
  • Program evaluation
 
 
Hospitals currently offering ECHO Epilepsy sessions are:
  • Hamilton Health Science Centre (Wednesdays)
  • Queen’s University, Division of Neurology (Thursdays)
 
Starting September 2019, the following hospitals will also offer ECHO sessions:
  • The Ottawa Hospital (Fridays)
  • London Health Sciences Centre and Thunder Bay Health Sciences Centre (Wednesdays)
  • CHEO (Mondays)
  • SickKids (Mondays)
  • McMaster Children's (Wednesdays)
  • Children's Hospital at London Health Sciences Centre (Thursdays)
  • University Health Network: Toronto Western Hospital (Tuesdays)
  
For more information and for the schedule, please visit our website

If you have any questions or concerns please contact:

Anastasia Vogt - Program Manager
• Phone: 416-813-7654 ex 309016
• E-mail: Anastasia.vogt@sickkids.ca

In order to support the growth of the ECHO movement, Project ECHO® collects participation data for each teleECHO™ program. This data allows Project ECHO to measure, analyze, and report on the movement’s reach. It is used in reports, on maps and visualizations, for research, for communications and surveys, for data quality assurance activities, and for decision-making related to new initiatives. The data is shared with the ECHO Institute at the University of New Mexico. By completing this survey, you are registering for the program, and agreeing to the use of your data for the above stated purposes.

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone Number 

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* 5. City/Town

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* 6. Clinic/Organization Postal Code
*Used to track regional participation

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* 7. Organization or Clinic Name

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* 9. Do you have an area of practice specialty or expertise (e.g., paediatrics, neurology, mental health, complex care, etc.)

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* 10. Primary Practice Setting

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* 11. Is your practice location in an urban/suburban, rural or remote setting?

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