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.

Collected information will be used by the project team for the following purposes:
  • Registration
  • Program evaluation
 
The registration form will take 5 minutes or less to complete.
 

The schedule for current ECHO Epilepsy sessions are:
  • University Health Network: Tuesdays from 1:00-2:30PM
  • Hamilton Health Science Centre: Wednesdays from 1:30-3:00PM
  • (COMING SOON) Kingston General Hospital: Thursdays from 12:30-2:00PM
  • (COMING SOON) London Health Science Centre: Wednesdays from 1:00-2:30PM
  • For more information, 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.

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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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