Project ECHO- Expanded Telehealth Services for COVID-19:
Making sense of the new rules

Registration

Question Title

* 1. Contact Information

Primary Contact Name *

Primary Contact Role *

Practice Name *

Address

City/Town *

State/Province *

ZIP/Postal Code *

Type of Practice *

Email Address *

Phone Number *

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* 2. List any additional potential participants from your practice

Name/Role/Email:

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

Yes

Comment

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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)?

Yes

Comment

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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?

Care team involvement and workflow efficiencies

Starting Telemedicine from the ground up

Chronic disease management utilizing telemedicine

Utilizing telemedicine for behavioral health and substance use disorder

Use of remote monitoring to improve outcomes

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* 7. Additional topics of interest?

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* 8. How did you hear about this?

Word of Mouth

Invite

Other (please specify)

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* 1. Contact Information

Question Title

* 2. List any additional potential participants from your practice

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 7. Additional topics of interest?

Question Title

* 8. How did you hear about this?

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* 9. Any additional comments