Tickborne Diseases 2022 ECHO Registration

Welcome to the Tickborne Diseases 2022 ECHO noon - 1 pm Thursdays in August.

Please register by providing the following information. Submission of this form will enroll you in all four courses.

Agendas, speaker slides and patient cases will be sent to the e-mail address you provide.

If you have any questions, please contact projectecho@kumc.edu.

Thank you!

Upload the series FINAL CLEAN PDF report here to provide to FUNDERS (with no source data links or notes)

Upload file

Upload the series FINAL CLEAN report here (with no source data links or notes)

Upload file

Upload the series FINAL report here (with all source data links and notes)

Upload file

Duplicate Record - If this is a duplicate registrant, designate if this is a duplicate or primary record

duplicate secondary record

duplicate primary record

Audit Trail

Audit Trail

Audit Trail

Administrative Notes

NOTE: For each note, please add the most current at the top of this field with a date and initials of the recorder

e.g.
2020 11-04 jw note goes here

2020 10-29 jl note goes here

Expand

FAQ 1

Must participants individually register or can an entire group be registered administratively (e.g. project echo/other proxy registrant)?

Response:
We look forward to the participation of your practice with our SUD 2022 ECHO. Because the Project ECHO learning platform allows all ECHO participants to interact with the specialty team and other learners during the live event, our program does require each participant to complete a brief registration form, which includes participation agreements and a disclosure statement. Additionally, our team needs the individual registrations to assist with attendance verification for our CE department.

Without these individual registrations, we are not able to meet our credentialing requirements. We have designed our registration to be a simple process that collects this information as efficiently as possible, and we look forward to your practice's participation.

Per:
Shawna Wright, Ph.D., LP, Associate Director, KU Center for Telemedicine & Telehealth
Clinical Assistant Professor (vol.), Dept. of Psychiatry and Behavioral Sciences

FAQ 2

Why didn't I receive a registration confirmation email? (or Why did projectecho@kumc.edu receive a failed message notification?)

Response:
Sometimes the registrant has a typo in their email field. Correct it and send an email to the new address per

Subject Line:

KUMC Project ECHO Registration Confirmation

Message Body:

Thank you FIRST NAME LAST NAME for registering for the KUMC SUD 2022 ECHO series.

We will send you reminders and documents to this email address before each course. If you prefer correspondence directed to another email address please notify us at projectecho@kumc.edu.

As a reminder: Your registration covers all courses of the series, so there is no need to re-complete this survey for each course.

ALL ECHO Roles = Registrant/Participant UNLESS indicated here

Please check ALL Roles this Registrant fulfills during this project/series

Planning Team Member

ECHO Staff

Continuing Education

Funder

Specialty Team Member/Expert

Facilitator

Observer

Lived Experience Contributor

Something Else

Is this your first ECHO?

* must provide value

Yes

reset

How examples

How did you hear about this ECHO Series? Please check all that apply.

* must provide value

KUMC/AHEC email announcement

K-State Extension announcement

Recommended by a friend or colleague

Partner agency or organization

Social media

Blog or publication

Search engine (e.g. Google, Yahoo, etc.)

Poster/printed posted announcement

Something else

Please describe why you selected "something else" here

First Name

* must provide value

Last Name

* must provide value

Email address

* must provide value

Secondary email address

Work Phone Number

Mobile Phone Number

What is your position/title?

* must provide value

Organization Name: Please provide the name of your primary health care delivery/work site.

* must provide value

Please provide the web address/URL for your of your primary health care delivery/work site.

Organization Address: Please provide the street address of your primary health care delivery/work site.

* must provide value

Organization City: Please provide the name of the city of your primary health care delivery/work site.

* must provide value

Organization State, Tribal Nation/Territory

Please select ALL that apply

* must provide value

Kansas (KS)

Tribal Nation Serving Kansans

Not Kansas

Please Specify the Tribal Nation Serving Kansans

* must provide value

The Iowa Tribe of Kansas and Nebraska

The Kickapoo Tribe in Kansas

The Prairie Band Potawatomi Nation

The Sac and Fox Nation of Missouri in Kansas and Nebraska

The Kaw Nation

Something else

reset

Please describe why you selected "something else"

* must provide value

Organization County: Please select your primary health care delivery/work site county in Kansas.

* must provide value

Organizational Location: United States (US), US Territory or Other Country

* must provide value

US State or Territory Organization (outside Kansas)

* must provide value

Organization County: Please select your primary health care delivery/work site county (outside Kansas).

* must provide value

Organization Zipcode: Please provide the zip code of your primary health care delivery/work site.

* must provide value

Country Other Than US: Please select the country in which you deliver health care/work. (outside of US)

* must provide value

This ECHO aims to serve human health and animal health professionals. Please select the answer which best describes your profession's population focus.

* must provide value

Human health

Animal health

reset

Please select the focus of your practice/work.

* must provide value

Please describe why you chose "something else."

* must provide value

Please select your primary practice/work activity.

* must provide value

Choose the principle setting of your health care delivery/work.

*Please review subcategories for choices listed here prior to selecting "something else."

* must provide value

Please describe why you chose "something else."

* must provide value

Select the Ambulatory/Outpatient Care Setting/Provider Office/Outpatient Clinic

NOTE:
(L) = Local Setting
(S) = State Setting

* must provide value

Please select your primary practice/work activity.

* must provide value

Please select the focus of your practice/work.

* must provide value

Please select your practice/work specialty/specialties.

* must provide value

Anesthesia

Animal Welfare

Behavior

Dentistry

Dermatology

Emergency and Critical Care

Internal Medicine

Internal Medicine: Cardiology

Internal Medicine: Neurology

Internal Medicine: Oncology

Laboratory Animal Medicine

Microbiology

Nutrition

Ophthalmology

Pathology

Pharmacology

Poultry Veterinarian

Preventive Medicine

Radiology

Sports Medicine and Rehabilitation

Surgery

Surgery: Orthopedics

Surgery: Soft Tissue surgery

Theriogenology

Toxicology

Veterinary Practitioner: Avian Practice

Veterinary Practitioner: Equine Practice

Veterinary Practitioner: Beef Cattle Practice

Veterinary Practitioner: Feline Practice

Veterinary Practitioner: Canine/Feline Practice

Veterinary Practitioner: Exotic Companion Mammal Practice

Veterinary Practitioner: Food Animal Practice

Veterinary Practitioner: Dairy Practice

Veterinary Practitioner: Reptile and Amphibian Practice

Veterinary Practitioner: Swine Health Management

Zoo Medicine

Select the Primary Setting of Your Practice or Work

* must provide value

Please describe why you selected "something else."

* must provide value

Select the Hospital or Emergency Care Setting

* must provide value

Please describe why you selected "something else."

* must provide value

Select the Home Health or Hospice Setting

* must provide value

Select the Post Acute or Long Term Care Setting

* must provide value

Please describe why you chose "something else."

* must provide value

Please select your professional group.

* must provide value

Please select your professional group.

* must provide value

Please describe why you chose "something else."

Please select your professional specialty.

* must provide value

Please describe why you chose "something else."

* must provide value

Please select your professional group.

* must provide value

Please describe why you chose "something else."

* must provide value

Please select your professional group.

* must provide value

Please describe why you chose "something else."

* must provide value

Please select your professional group.

Please describe why you chose "something else."

* must provide value

Please select your professional role.

* must provide value

Please describe why you chose "something else."

* must provide value

Your Education

More than one may be selected.

* must provide value

ADN

AuD

BSN

DDS

DMD

DNP

DPM

DPT

DrPH

DSW

DVM

EdD

High School Diploma/GED

MBA

MBBS

MHSA

MOT

MPA

MPH

MPT

MSN

MSW

NMD

OTD

PharmD

PhD (non-public health)

PhD (public health)

PsyD

ScD (non-public health)

ScD (public health)

VMD

Something else

Please describe why you chose something else. If listing multiple, please separate each with a comma.

* must provide value

Your Credentials

Please select all that apply.

AEMT

APHN

APRN

BHW

CAN

CCC-A

CCC-SLP

CCRP

CHES

CMA

CNM

CNM-I

CNS

CRC

CRNA

EHS

EMR

EMT

FNP

HHA

LaBA

LAC

LAc

LBA

LBSW

LCAC

LCMFT

LCP

LCPC

LMAC

LMFT

LMLP

LMSW

LPC

LPN

LRT

LSCSW

LSW

LVN

Master CHES

MFT

MHC

MICT

ND-A

OTA

OTD

PA-C

PTA

Something else

Please describe why you chose something else. If listing multiple, please separate each with a comma.

* must provide value

Participation is the Key to ECHO's success.

Unlike a webinar, participants and facilitators learn from each other fostering a more engaging and interactive learning experience. Participation brings a community of learning together.

Case-Based Learning

An important collaborative learning component of each ECHO course is discussing de-identified patient cases. All participants are encouraged to engage throughout the case-based learning segment by sharing questions, knowledge, experience, and expertise. This is a valuable opportunity to collaborate and consult with other providers to improve patient care.

Volunteer to Share Your Case for Discussion

Sharing de-identified patient cases is a vital component of each ECHO course. Our case coordinator will support you throughout the entire process from planning through presentation. The rich discussion between specialty team members, you, and your participating colleagues not only helps the provider submitting the case, it helps the entire community of practice with similar patient issues.

We encourage everyone to submit a patient case to receive new insight into the case or submit an interesting case you have had success with and would like to share.

During which course would you like to present your case? You may choose one or more courses to present case(s) for all participants' learning. Please select at least one course you are interested in presenting a patient-based case.

I Agree to Share My Case at Course 1

I Agree to Share My Case at Course 2

I Agree to Share My Case at Course 3

I Agree to Share My Case at Course 4

Any course

Perhaps, but I'd like to learn more, please contact me

******THIS FIELD WAS SPECIFIC TO DEMOGRAPHIC PROVIDER TARGETS FOR ONE ECHO FUNDER'S GRANT AND RETAINED HERE AS A PLACEHOLDER SAMPLE FOR FUTURE ECHO PROJECTS******For registrants indicating interest in case presentation (via this form or another communication), select their case presentation status.

Target county = NOW Coalition grant area:
Pratt
Barber
Comanche
Edwards
Harper
Kiowa and
Stafford

confirmed

potential

declined

withdrew

confirmed: RCORP County

potential: RCORP County

declined: RCORP County

confirmed: Other SE County

potential: Other SE County

declined: Other SE County

reset

For potential or confirmed case presenters, indicate their assigned course below.

Please download the attached file for your calendar appointment(s).

Attachment:Tickborne Disease 2022 ECHO.ics

Lyme Disease is the most common tickborne disease in Kansas.

* must provide value

True

False

reset

Where are ticks most likely to be found?

* must provide value

Along trails and paths with vegetated margins

In brushy areas

On pets such as dogs, cats, and rabbits that have outdoor access

On deer, turkeys, and other animals caught by hunters and fur trappers

All of the above

reset

The preferred initial test to diagnose Lyme Disease is a Western Blot (Immunoblot) assay, which then reflexes if positive to an ELISA.

* must provide value

True

False

reset

John Doe presents to his primary care physician in Southeast Kansas with 5 day history fevers, headache and today developed rash along his wrists. A week prior to onset he removed a tick, but did not examine it. What is John most likely presenting with?

* must provide value

Psychosis from methamphetamine use is usually untreatable and irreversible.

* must provide value

True

False

reset

SEE PAGES 44 & 45 of RAND article

Please check all that apply to describe your opinion of the value of this Project ECHO Series

No-cost educational opportunity

No-cost CE is my chief motivation

No-cost CE is a very important consideration

No-cost CE is nice too

My Telehealth "Story of Now" of a Primary Care Approach to Managing Substance Use Disorders

Take a moment to share a brief story that describes how telehealth made a positive difference during the pandemic and your telehealth recommendations to sustain/increase its impact on this population post pandemic.

Current Professional Practices --- this is typically a section header field

* must provide value

Which of the following best describes your professional practices related to substance use disorder (SUD) screening?

* must provide value

Please describe your selection:

"I do not currently screen for SUD and have no plans to start screening"

* must provide value

Which of the following best describes your professional practices related to MAT-waivers?

* must provide value

Please describe your selection:

"I do not currently have a MAT-waiver and have no plans to complete MAT-waiver training"

* must provide value

Please describe why you selected "something else"

* must provide value

Which of the following best describes your professional practices related to partnerships with your local pharmacist(s)?

* must provide value

Please describe your selection:

"I do not currently have a partnership with a local pharmacist related to opioid use disorder (OUD) care"

* must provide value

Please describe why you selected "something else"

* must provide value

Header Field:
Palliative Care & Quality of Life Needs Assessment
The Kansas Palliative Care and Quality of Life Advisory Council is seeking information to inform development of the State Plan. Your experiences and recommendations are valued.

NOTE: Data will be shared in aggregate only with no identifying information.

Paragraph Field:
What do you think would be the most valuable resource/tool in your daily practice to enhance your knowledge of palliative care?

* must provide value

Expand

What is your current access to palliative care in your community?

* must provide value

Expand

Would you have interest in attending trainings specific to developing primary palliative care skills or care planning for patients with serious illness?

* must provide value

Expand

Is there anything else you would like to share with palliative care advisory council members?

Expand

Do you provide patient care?

* must provide value

Yes

reset

I will be requesting Continuing Education Credit

* must provide value

Yes

reset

Continuing Education Credit for each course offered during this series is detailed below.

• APRNs/Nurses: The University of Kansas Medical Center Area Health Education Center East is approved as a provider of CNE by the Kansas State Board of Nursing. This course offering is approved for 1.0 contact hours applicable for APRN, RN, or LPN relicensure. Kansas State Board of Nursing provider number: LT0056-0749. Mary Beth Warren, MS, RN, Coordinator

Nursing attendance requirement: Presentations must be attended in their entirety to claim credit.

• Physicians: The University of Kansas Medical Center Office of Continuing Medical Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The University of Kansas Medical Center Office of Continuing Medical Education designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

• Veterinarians: This program has been approved for up to 4 hours of continuing education credit in jurisdictions which recognize American Association of Veterinary State Boards (AAVSB) Registry of Approved Continuing Education (RACE®) approval.

Other participants may receive a certificate of attendance upon completion of requested documentation and evaluation.

• Turn your camera (ON)
• Make sure your full name is entered. (RENAME)
• Use the (CHAT) function to introduce yourself and type in any comments and/or questions.
• Select (LEAVE MEETING) when the meeting is done.

Check out "Teleconferencing Tips" !!!

Attachment:TeleECHO Video Conferencing Tips Sldeshow.pptx

By Clicking "I Agree" below you agree to and understand the following:
• TeleECHO courses will be recorded and I consent to being recorded.
• I understand recorded images may be used for marketing purposes
• I will adhere to HIPAA guidelines.
• I will keep my camera on to foster engagement and collaboration.
• I will complete the post series evaluation.

Project ECHO collects registration, participation, questions/answers, chat comments, and poll responses for some TeleECHO programs. Your individual data will be kept confidential. These data may be used for reports, maps, communication, surveys, quality assurance, evaluation, research, and to inform new initiatives.

* must provide value

I agree

Please select the most accurate statement regarding Relevant Financial Disclosure

* must provide value

Please list any potential conflicts

Please click "Add Signature" and sign with your mouse or finger.

* must provide value

Add signature

Please take a moment to strengthen and grow YOUR practice community by sharing this registration link with your physician, veterinarian, nurse, and advance practice clinician colleagues.

Simply forward the announcement you've received or copy this link to share!

Register at: https://bit.ly/TickborneDiseases-2022

Please share any additional comments you have for the KUMC Project ECHO team.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.