AAP and AFSP Suicide Prevention ECHO Interest Form

Thank you for your interest in the American Academy of Pediatrics (AAP) and American Foundation for Suicide Prevention (AFSP) Suicide Prevention ECHO program.

If you are interested in participating in future ECHO programs on the topic of suicide prevention and/or would like to request more information, please submit your information through this survey.

Contact Jessie Leffelman, Program Manager, at jleffelman@aap.org with any questions.

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* 1. Please enter your name, email address, and phone number below:

Name:

Credentials:

Email address:

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* 2. Are you a member of the American Academy of Pediatrics?

Yes

If yes, please include your AAP ID:

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* 3. Professional Organization Information:

Name

State

ZIP/Postal Code

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* 4. Which ECHO are you interested in learning more about?

Suicide Prevention Clinical ECHO for Primary Care

Suicide Prevention Clinical ECHO for School-based Health Care

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* 5. Are you interested in participating in quality improvement?

Yes

Unsure at this time

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* 1. Please enter your name, email address, and phone number below:

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* 2. Are you a member of the American Academy of Pediatrics?

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* 3. Professional Organization Information:

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* 4. Which ECHO are you interested in learning more about?

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* 5. Are you interested in participating in quality improvement?

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* 6. If you have any questions or requests, please feel free to submit them below or contact Jessie, Program Manager, at jleffelman@aap.org.