Your Demographic and Contact Information

Thank you for your interest in the Paediatric Epilepsy Learning Day, hosted by Project ECHO Ontario: Epilepsy Across the Lifespan!

The Paediatric Learning Day will be held on March 26th, 2019 from 10:00 a.m. to 5:00 p.m. at the Peter Gilgan Centre for Research and Learning in Toronto.

We'd like to learn a little more about you, your interest in Epilepsy 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.

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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* 8. Profession

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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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* 12. Approximately how many of your patients have Epilepsy?

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* 13. Please briefly let us know what you are hoping to learn from the Paediatric Epilepsy Learning Day

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