The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

AGIvsP2Q55CCXmCQeEB9GzfnboQfY7JT5dDNvqwyejNWkJzvFkk48nTgihkzIP8hcuhskfrrthPHHLGCWzbFcDbgqW4PZEJB9bZmRZfjgfiivFxMKkx4mEWRYiV5n

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 course to the e-mail address you provide.

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

Thank you!

iECHO 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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How many courses are in this series?

Course 1 Date

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

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 Thursday, 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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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

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

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

FIELD DEVELOPMENT IN PROGRESS Jacqueline Belden - KUMC Project ECHO to Everyone (Feb 28, 2025, 12:10 PM)
https://kic.kdheks.gov/OHA/ksmap.html#district

Jacqueline Belden - KUMC Project ECHO to Everyone (Feb 28, 2025, 12:15 PM)
Use Kansas Trauma and EMS Regions map
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

Please select your primary practice/work activity.

* must provide value

Please select your professional role.

* must provide value

Please describe why you chose "something else."

* 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.

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

Attachment:RETAINWORKS 2025 ECHO Enhancing Health Through Whole-Person Care and Employment.ics

Have you worked with clients/patients who are experiencing difficulty achieving their stay-at-work or return-to-work goals after or during an injury or illness 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 supporting clients/patients who wish to stay-at-work or return-to-work after or during an injury or illness and believe you could benefit from additional resources or consultation with specialists?

Briefly describe:

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Please select the choice which best describes your involvement with the RETAINWORKS Program or its participants.

* must provide value

I am a RETAINWORKS-affiliated health service provider

I am involved with RETAINWORKS but not as a health service provider

I am not involved with RETAINWORKS

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Please select the choice which best describes your involvement with RETAINWORKS.

* must provide value

I am employed to support RETAINWORKS efforts within an affiliated health system

I am employed to support RETAINWORKS efforts within a workforce center

I am an employer (or employed by an employer) who supports its workers' RETAINWORKS participation

I am employed to support RETAINWORKS efforts within the State of Kansas (e.g., Department of Commerce)

I have referred one or more patients/clients for participation in RETAINWORKS

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Please select your RETAINWORKS-affiliated health system.

* must provide value

Please select your RETAINWORKS workforce partner organization.

* must provide value

Please provide the name and address of the employer partnered with RETAINWORKS if it is different than the organization details you provided earlier on this form, or indicate N/A.

* must provide value

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Very Often

Sometimes

Rarely

Never

N/A

Collaborate with the employers of patients/clients?

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Collaborate with workforce systems?

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Use tailored stay-at-work or return-to-work strategies based on patient's/client's needs and work settings?

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Use JAN (Job Accommodations Network)?

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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 enhancing health through whole-person care and employment by sharing this registration link with your

ENTIRE TEAM: physicians, advanced practice clinicians, behavioral health clinicians, physical therapists, occupational therapists, workforce professionals and employers.

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

Register at:

https://bit.ly/RETAINWORKS2025ECHO

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.