TransECHO Application for January - December 2019 Session

Thank you for your interest in TransECHO. This is an opportunity for your health center to learn from experts and apply those learnings to increase the availability of culturally-responsible, comprehensive primary care for transgender and gender non-binary people. TransECHO uses the Project ECHO model in conjunction with the application of practice transformation principles. Your health center will work alongside other health centers to create systems of care that support your transgender and gender non-binary patients.

The first TransECHO session will be January 24, 2019 from 2-4pm ET and will continue every 4th Wednesday of the month for 12 months. Participants are expected to attend every session. Applicants will be notified of their acceptance into the cohort by December 3, 2018. Accepted organizations will be required to attend a 20 minute orientation call in December.

Question Title

* 1. Are you filling this application out on behalf of another participant?

Yes

Question Title

* 2. Please enter your contact information.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 3. ECHO Participant Contact Information - if different from above.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 4. Is your organization a Federally Qualified Health Center (FQHC) or FQHC look alike?

Only FQHCs and look alikes are eligible for participation in TransECHO. If you are not sure of your status, please submit a complete application and we can be in contact about your specific situation via email.

Yes

I'm not sure

Question Title

* 5. What is your organization's approximate practice size (as measured by annual patient visits)?

Hospital (>500,000 visits)

Large clinic (100,000-499,999 visits)

Medium clinic (45,000-99,999 visits)

Small clinic (10,000-44,999 visits)

Private practice/Single provider (<10,000 visits)

TransECHO Application for January - December 2019 Session

Question Title

* 1. Are you filling this application out on behalf of another participant?

Question Title

* 2. Please enter your contact information.

Question Title

* 3. ECHO Participant Contact Information - if different from above.

Question Title

* 4. Is your organization a Federally Qualified Health Center (FQHC) or FQHC look alike?

Only FQHCs and look alikes are eligible for participation in TransECHO. If you are not sure of your status, please submit a complete application and we can be in contact about your specific situation via email.

Question Title

* 5. What is your organization's approximate practice size (as measured by annual patient visits)?

Question Title

* 6. Please describe your interest in participating in TransECHO.

Question Title

* 7. Can you describe the buy-in you have from senior leadership?

Question Title

* 1. Are you filling this application out on behalf of another participant?

Question Title

* 2. Please enter your contact information.

Question Title

* 3. ECHO Participant Contact Information - if different from above.

Question Title

* 4. Is your organization a Federally Qualified Health Center (FQHC) or FQHC look alike? Only FQHCs and look alikes are eligible for participation in TransECHO. If you are not sure of your status, please submit a complete application and we can be in contact about your specific situation via email.

Question Title

* 5. What is your organization's approximate practice size (as measured by annual patient visits)?

Question Title

* 6. Please describe your interest in participating in TransECHO.

Question Title

* 7. Can you describe the buy-in you have from senior leadership?