KUMC Project ECHO Series Registration

Welcome to the ______ series ______.

Please register by providing the following information. Agendas, didactic and case presentation slides will be sent in advance of each session to the e-mail address you provide.

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

Thank you!

iECHO ID

For DY troubleshooting - Timeframe of surveys with timestamp [not completed] and missing identifying/demographic information

Timestamp pre record id and Timestamp post record id

Data Management: Completion Status

Registration Complete

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Course 1 Attended

______

Yes

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Course 2 Attended

______

Yes

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Course 3 Attended

______

Yes

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Course 4 Attended

______

Yes

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Course 5 Attended

______

Yes

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Course 6 Attended

______

Yes

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Course 7 Attended

______

Yes

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Course 8 Attended

______

Yes

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Course 9 Attended

______

Yes

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Course 10 Attended

______

Yes

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Course 11 Attended

______

Yes

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Course 12 Attended

______

Yes

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Course 13 Attended

______

Yes

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Course 14 Attended

______

Yes

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How many sessions/courses are in this series?
@SETVALUE = 'replace this set value text with the number of sessions/courses' e.g. @SETVALUE = '2'

Course 1 Date

DONNA REMOVE ALL DATE FIELDs' (@)SETVALUEs > # of sessions, e.g., 3 session series, delete course dates 4+ OR the set value action tag's value

M-D-Y

Course 2 Date

M-D-Y

Course 3 Date

M-D-Y

Course 4 Date

M-D-Y

Course 5 Date

M-D-Y

Course 6 Date

M-D-Y

Course 7 Date

M-D-Y

Course 8 Date

M-D-Y

Course 9 Date

M-D-Y

Course 10 Date

M-D-Y

Course 11 Date

M-D-Y

Course 12 Date

M-D-Y

Course 13 Date

M-D-Y

Course 14 Date

M-D-Y

Short Series Title for this ECHO

NOTE: This is the Final Title's categorical information preceding the ":" e.g., OD2A SUD 2023 ECHO
NOTE: If course is one session only, then the Series Title = Session Title

Series Schedule for this ECHO

NOTE: This is Final Series Schedule of (timeframe, weekday and duration): "" e.g.,
noon - 1 pm each Wednesday, February 15 through March 14, 2024

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

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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

Guest Speaker

Facilitator

Observer

Lived Experience Contributor

Something Else

Is this your first ECHO?

* must provide value

Yes

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Did you attend the prior School-based Mental Health ECHO series that occurred from 2023-2024?

* must provide value

Yes

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How examples

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

* must provide value

KUMC/AHEC email announcement

KUMC Project ECHO Webpage

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

Your Primary Education/Work Site

* must provide value

Your Primary Education/Work Site

* must provide value

IF you serve more than one school district/interlocal cooperative, note it here.

Otherwise, SKIP
this item and go the the next one.
* must provide value

What academic level are students you serve? (please select all that apply)

* must provide value

Pre-K

Elementary School

Middle School

High School

K-12

Not Applicable

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

* must provide value

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

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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

2024 Kansas Fights Addiction County Index Ranking

* must provide value

This field indicates when a county is in the Kansas Fights Addiction (KFA) 5th Quintile

Indicators used to determine county index rankings include: overdose emergency department visits per capital, overdose fatalities per capita, percentage of households below poverty, and percentage of adult frequent mental health distress.

Source: https://sunflowerfoundation.org/wp-content/uploads/2024/03/KFA-County-Index-Map-2024.pdf

2024 Kansas Fights Addiction County Index Ranking

* must provide value

2024 Kansas Fights Addiction County Index Ranking

* 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

Please select your primary practice/work activity.

* must provide value

Please select your professional role.

* must provide value

School Nurse

School Counselor

School Social Worker

School Psychologist

School Administrator

District Administrator

Board of Education Member

School Resource Officer

Other School-Based Professional

Non School-Based Professional

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Please describe why you chose "Other School-Based Professional"

* must provide value

Please describe why you chose "Non School-Based Professional"

* must provide value

(Optional) What is your position/title?

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.

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

Attachment:School-Based Mental Health 2025-26 ECHO Advancing Prevention Initiatives for Kansas Youth.ics

Have you worked with students or families who are at risk of or affected by substance use and believe you could benefit from additional resources or consultation with specialists?

Briefly describe:

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Have you experienced barriers or obstacles to implementing prevention initiatives for PreK-12 students in your school, district, or community and believe you could benefit from additional resources or consultation with specialists?

Briefly describe:

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Pretest Item #1:
Typical Field Type = Multiple Choice - Radio Buttons (Single Answer), Yes-No, or True - False.

e.g., Screening for substance use disorder can be as simple as using a single question.

* must provide value

True

False

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Pretest Item #2:
Typical Field Type = Multiple Choice - Radio Buttons (Single Answer), Yes-No, or True - False.

e.g., Fentanyl test strips are considered legal to distribute or possess in Kansas.

* must provide value

True

False

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Pretest Item #3:
Typical Field Type = Multiple Choice - Radio Buttons (Single Answer), Yes-No, or True - False.

e.g., Rates of overdose from which drugs have contributed most to the increase of overdose deaths in Kansas over the last 2 years?

* must provide value

Heroin and cocaine

Heroin and methamphetamine

Fentanyl and methamphetamine

K2 and spice

Prescription opioids and benzodiazepines

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Pretest Item #4:
Typical Field Type = Multiple Choice - Radio Buttons (Single Answer), Yes-No, or True - False.

e.g., How much training is required for prescribers to obtain the ability to treat up to 30 patients with buprenorphine for opioid use disorder?

* must provide value

8 hours for physicians and 24 hours for nurse practitioners, physician assistants, and other advance practice providers

No training-all prescribers are allowed to prescribe buprenorphine without restriction

No training, but prescribers must complete notification of intent through SAMHSA

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Pretest Item #5:
Typical Field Type = Multiple Choice - Radio Buttons (Single Answer), Yes-No, or True - False.

e.g., The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain do not apply to pain management related to sickle cell disease, cancer-related pain treatment, palliative care, or end-of-life care.

* must provide value

True

False

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Current Professional Practice(s) Items Target Respondent

e.g., Are you a prescribing provider?

* must provide value

Yes

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Current Professional Practice(s) Items Target Respondent

May be dependent upon response to tr1

e.g., Do you prescribe narcotics?

* must provide value

Yes

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Current Professional Practice(s) Items Target Respondent

May be dependent upon response to tr or tr1a

e.g., Do you have comfort prescribing new narcotics?

* must provide value

Yes

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Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I feel confident in my ability to identify students who may be at risk for substance use.

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I feel confident in my ability to initiate conversations with students about substance use.

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Harm reduction strategies are appropriate for school-aged children and adolescents.

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Harm reduction strategies are appropriate for school-aged children and adolescents.

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Schools should take an active role in addressing student substance use.

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My school has adequate resources to support substance use prevention efforts.

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Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Matrix #2 Item CPP 1

Matrix #2 Item CPP 2

Matrix #2 Item CPP 3

Matrix #2 Item CPP 4

Matrix #2 Item CPP 5

Matrix #2 Item CPP 6

Matrix #2 Item CPP 7

Matrix #2 Item CPP 8

Matrix #2 Item CPP 9

Matrix #2 Item CPP 10

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Other

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Do you have a prevention initiative in place at your school/district to address substance use?

* must provide value

Subsequent Item to **Outcome/Change #1**
May be dependent upon response to cpp1a or cpp1b

e.g., Would you be interested in more training to begin cpp1a?

* must provide value

Yes

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Does your school/district collaborate with a coalition or other organization to provide prevention programming to students to address substance use?

* must provide value

Which of the following best describes your utilization of the strategy:

**Outcome/Change #2**

* must provide value

Which of the following best describes your utilization of the strategy:

**Outcome/Change #3**

* must provide value

Which of the following best describes your utilization of the strategy:

**Outcome/Change #3**

* must provide value

OPTIONAL INITIATIVE - see planning form for details - if so, customize the short title below and add a section header ECHO Plus field above. Remove all red colored text. if not, tag this field as @HIDDEN-SURVEY

Would you and/or your practice be interested in taking the next step toward driving meaningful practice change by joining an ECHO Plus cohort focused on implementing insights from RETAINWORKS 2025 ECHO?

Participants will receive a stipend along with additional resources, including marketing and promotional support, as well as access to advanced training and mentorship programs to elevate your practice.

Yes

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By selecting "I agree," you understand and agree to the following:

Project ECHO sessions will be recorded
Recordings and images may be used for marketing purposes
First and last names are required to be displayed during ECHO sessions to claim continuing education credit
Following HIPAA guidelines is a requirement of ECHO participation
Project ECHO will communicate all ECHO information via email (these communications can be opted out of at any time)
Promotion or sale of products, services, or personal business interests during ECHO sessions is strictly prohibited

The data collected during registration and ECHO sessions is kept strictly confidential and is not shared with any third parties. It is used only for deidentified reports, quality assurance, research and future programming.

* must provide value

I agree

In the past 24 months, have you and/or your spouse or partner had, or do you have, a financial relationship(s) with any ineligible companies?
Ineligible companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

* must provide value

Yes

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

* must provide value

Add signature

Please take a moment to strengthen and grow our community of practice for student wellness by sharing this registration link with your ENTIRE TEAM: School counselors, school nurses, school psychologists, school social workers, school and school district administrators and leadership, prevention specialists, law enforcement, and community mental and behavioral health professionals.

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

Register at: https://bit.ly/SBMH2025-26ECHO

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.