Asthma Essentials ECHO Registration

Participant Information

Why Asthma ECHO:

Asthma is one of the most common and costly conditions in the United States. In RI, around 1 in 12 people have asthma. Asthma can be controlled with self management education, appropriate medical care and avoiding exposure to environmental triggers. Even though asthma is controllable, an estimated 50% of children with asthma have uncontrolled asthma and 40% of adults who had asthma reported having one or more asthma attacks in the past year.

To learn more about the Asthma Essentials ECHO view the flier here

All participants must complete this pre-survey (click here to access)

For questions, email Michelle Mooney, MPA, Program Coordinator: mmooney@ctc-ri.org

Question Title

* 1. Your Information

First Name

Last Name

Position Title

Email Address

Work Phone Number

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* 2. Job Category

Provider (MD, DO, NP, PA)

Community Health Worker

School Nurse

Health Equity Zone

Community Based Organization

Respiratory Therapist

Pharmacist

EMT

Patient Health Navigator

Other (please specify)

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* 3. Organzation Information

Org Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 4. Area of Speciality

Adult Medicine

Community Advocate

Environment Health

Family Medicine

Pediatric Medicine

School Nurse

Specialist

Teachers Aid

Other (please specify)

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* 5. Type of Work Setting

Clinical Setting

School Setting

Community Setting

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* 6. Approximately what percentage of your patients have the following insurances

Public Insurance

Private Insurance

Dual Insured

No Insurance

N/A/I Don't know

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* 7. Have you participated in another ECHO before?

Yes

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* 8. If yes, which one(s)?

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* 9. Please indicate if there are other people from your organization/practice who will be attending.

Yes

I don't know at this time

N/A