SVSU SUD Project ECHO Registration

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

Street

City/Town

County

State

Zip Code

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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

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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* 11. 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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* 12. Are you interested in any of the following?

Continuing Medical Education Credits (CMEs)

Social Work Continuing Education Credits

Michigan Certification Board of Addiction Professionals Continuing Education Credits

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

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* 13. Are you currently a student

Yes

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* 14. Do you currently have a DATA 2000 waiver to prescribe buprenorphine?

Yes

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* 15. If you do not have a DATA 2000 waiver to prescribe buprenorphine, do you intend to apply for a waiver?

Yes

Unsure

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* 16. Do you currently prescribe buprenorphine for substance use disorder treatment?

Yes

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* 17. If you do prescribe buprenorphine, what is the average number of patients you are actively treating with buprenorphine? (please indicate a number)

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* 18. If you have any questions or concerns please contact:
Kari Peckham, Administrative & IT Coordinator
email: echo@svsu.edu
phone: 989-964-2883

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 and potential publication, 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.