NMU Rural Health Equity Project ECHO Registration

Your Demographic and Contact Information

Thank you for your interest in Northern Michigan University Rural Health Equity Project ECHO: Social Determinants of Health
We'd like to learn a little more about you, your interest in Project ECHO, and your practice. We ask that each individual in your organization who is attending the sessions register. It is only necessary to register one time and you will receive notices of all upcoming sessions.

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* 1. First Name

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* 2. Last Name

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* 3. What is your age range?

20-29

30-39

40-49

50-59

60+

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* 4. What is your gender?

Male

Female

Transgender

Other

Prefer not to answer

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* 5. What is your race?

White

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

More than one race

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* 6. What is your ethnicity?

Hispanic or Latino

Non Hispanic or Latino

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* 7. Have you ever served in the military?

Yes

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* 8. Do you meet federal criteria to qualify as "economically disadvantaged"? Check YES if you
meet either or both of the two criterion below:
You and/or your family receives public assistance (e.g., Temporary Assistance to Needy
Families, Supplemental Nutrition Assistance Program, Medicaid, and public housing).
You and/or your family fall below the 200% threshold for Family Poverty Guidelines (FPG), as
determined by annual income and family size. Please see the table below, to see if your
income falls below the 200% FPG threshold.
2022 HHS Poverty Guidelines
200% FPG Thresholds
Household Size Annual Income
1 $27,180
2 $36,620
3 $46,660
4 $55,500
5 $64,940
6 $74,380

Yes

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* 9. Are you a first generation college student?

Yes

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* 10. Email Address

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* 11. Phone Number

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* 12. Organization or Clinic Name (Used to track regional participation)

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* 13. Clinic/Organization Address

Street

City

County

State

Zip Code

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* 14. Job Title

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* 15. Credentials

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* 16. Do you have an area of practice specialty or expertise (e.g., pediatrics, neurology, mental health, complex care, addictionology, etc.)

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* 17. Primary Practice Setting

Primary Care or Family Practice

Federally Qualified Health Center or Community Health Center

Indian Health Access Center (AHAC)

Academic Hospital

Community Hospital (Non-academic)

Private Practice

Academic Institution

Acute Care Hospital

Rural Access Hospital

Community Mental Health Authority

Other (please specify)

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* 18. Is your practice location in an urban/suburban, rural or remote setting?

Urban/suburban (an area with a population over 30,000 people)

Rural (an area with a population of less than 29,999 and more than 30 minutes from a community with a population of greater than 30,000 people)

Remote (an area without year-round road access and/or relies on other mode of transportation to access suburban/urban center for part or all of the year)

Other (please specify)

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* 19. Are you interested in any of the following?

Continuing Medical Education Credits (CMEs)

Social Work Continuing Education Credits

Substance use focused credits

Community Health Worker credits

Other (please specify type of Continuing Education Credit and Accrediting Body)

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* 20. Are you currently a student

Yes