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Required format:

kGGojyYbszSKCkwKegiRFjWKL

ECHO FASD 2022 Registration

Thank you for your interest in ECHO FASD! This survey is used to collect information for registration or to allow us to contact you for more information. If you do decide to participate, this information will be used for attendance purposes and CME/CEU.

First Name:

* must provide value

Last Name:

* must provide value

Email Address:

* must provide value

Phone Number:

* must provide value

I would like:

* must provide value

More information about ECHO FASD so that I can decide if I would like to participate

To register for ECHO FASD

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Primary Degree:

* must provide value

Other:

Mailing Address:

Birth Date (MM/DD):

* must provide value

If you are a social worker, please note your license number:

How many years have you been in practice?

What is your gender?

What is your age in years?

What is your professional role? (Select all that apply)

Pediatric Nurse Practitioner

Family Nurse Practitioner

Psychiatric Nurse Practitioner

Pediatrician

Family Medicine Physician

Psychiatrist

Physician Assistant

Other (please specify):

Have you had specific training in the diagnosis or treatment of children with Fetal Alcohol Spectrum Disorder?

Yes

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If yes, please indicate the type of training you have received (check all that apply)

Content within a graduate-level course

Workshop

Conference presentation

Continuing Medical Education seminar

Webinar

Rotation during professional training

Other (please specify):

Why are you interested in participating in FASD ECHO? (choose all that apply)

Opportunity for networking with colleagues

Access to specialists for your patients

CME

Desire to learn more about FASD

Desire to be more comfortable treating children with complex behavioral presentations?

Other (please specify):

How did you hear about this program?

Word of mouth from a colleague

Word of mouth from a patient

Social media

Website

Employer/Name of Practice:

Zip Code of Practice:

What descriptor best characterizes your practice?

* must provide value

Primary Care Pediatrics

Primary Care Family Medicine

Outpatient Mental Health

Inpatient Mental Health

School Based Health Center

Residential Treatment program

Juvenile Justice program

Subspecialty Care (please specify)

Other (please specify):

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What is your practice setting?

Solo Practice

Private group practice

Academic medical center

Federally Qualified Health Center

Other (please specify):

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What percentage of the children in your practice have public insurance (Medicaid, Medicaid Managed Care, Child Health Plus)?

< 10%

10-25%

26-50%

51-75%

More than 75%

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If you have any questions, please contact Lynn Cole at lynn_cole@urmc.rochester.edu

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