Registration  

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* 1. Contact Information

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* 2. List any additional potential participants from your practice

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* 3. Will you be willing to share challenges and barriers you are experiencing and participate in discussions?  

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* 4. Do you have access to the following technology: a computer, webcam, internet and phone (if computer speakers do not work)?

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* 5. What are you hoping to gain from participation in this Project ECHO?

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* 6. We want to build a program that best meets your needs. Please rank the priority of the following educational topics?

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* 7. Additional topics of interest?

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* 8. How did you hear about this?

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* 9. Any additional comments

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