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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.
1.First Name(Required.)
2.Last Name(Required.)
3.What is your age range?
4.What is your gender?
5.What is your race?
6.What is your ethnicity?
7.Have you ever served in the military?
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
9.Are you a first generation college student?
10.Email Address(Required.)
11.Phone Number
12.Organization or Clinic Name (Used to track regional participation)(Required.)
13.Clinic/Organization Address(Required.)
14.Job Title
15.Credentials(Required.)
16.Do you have an area of practice specialty or expertise (e.g., pediatrics, neurology, mental health, complex care, addictionology, etc.)
17.Primary Practice Setting
18.Is your practice location in an urban/suburban, rural or remote setting?
19.Are you interested in any of the following?
20.Are you currently a student
Current Progress,
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