Your Demographic and Contact Information

Thank you for your interest in Saginaw  Valley State University's Project ECHO:  Substance Use Disorders
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. Email Address

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* 4. Phone Number

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

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* 6. Clinic/Organization Address

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* 7. Job Title

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* 8. Credentials

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* 9. Do you have an area of practice specialty or expertise (e.g., pediatrics, neurology, mental health, complex care, addictionology, 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. Are you interested in any of the following?

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* 13. Are you currently a student

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* 14. If you have any questions or concerns please contact:
Trisha Charbonneau-Ivey, Project Manager
email: tkcharbo@svsu.edu
phone:  989-964-7161

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. 

In addition to the above, in order to facilitate Project ECHO®, Saginaw Valley State University will be capturing photographs, recording each ECHO® session, and recording planning meetings. These photographs and recordings will be used as a resource, for future training, for academic presentations and publicity. By voluntarily submitting your questionnaire, you are giving Saginaw Valley State University permission to use data entered into this survey.

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