Hennepin Healthcare Training Center

Describe your case or story and your main question you would like addressed by the ECHO participants.

Note: If you do not have information for a category, just insert "unknown", "not applicable (NA)" or a blank space to move to the next question.

Do not include any Protected Health Information (PHI).

By submitting this survey you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between any ECHO clinician and any patient whose case is being presented.

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* 1. Your name and your facility name.

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* 2. Please state your Story or Case.

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* 3. Please state your question(s) for the group.

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