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Maine AHEC Network Caring for the Roots Project ECHO Participant Registration Form & Statement of Collaboration

Please register for the Maine AHEC Network's Caring for the Roots Project ECHO via the form below.

Please reach out to ceph-edu@une.edu with any questions or difficulties.

Thank you!

Participant First Name

* must provide value

Participant Last Name

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Degree/License Type (e.g., MD, DO, APRN, RN, etc...)

* must provide value

APRN

LCSW/LMSW

CHW

PharmD

Dentist

Dental Hygienist

Admin

Leadership (e.g., CEO, COO, practice manager, etc...)

Other

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How do you describe your gender identity? (select all that apply)

Agender

Man

Non-binary

Questioning/Unsure

Transgender

Woman

Other identity not listed

Describe:

How do you describe your race/ethnicity? (select all that apply)

Hispanic/Latino

Non-Hispanic/Latino

American Indian or Alaska Native

Asian

Black or African American

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Multi-racial

Prefer to self-describe

Describe:

Telephone

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Organization/Practice/Worksite Name

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Organization/Practice/Worksite Street Address

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Organization/Practice/Worksite Town/State/Zip

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Are you joining Project ECHO as part of a team within your practice or organization?

Yes

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Participant Commitment & Statement of Collaboration:

I have read the Program Overview and by signing this form, I agree that I am committed to working with Project ECHO at UNE and will:

Participate in each Project ECHO case‐based learning session, using a virtual meeting platform (see program schedule, 3 sessions total)
- Each virtual learning session is 60 minutes in duration and will consist of a case presentation and brief lecture with Q&A. Internet access and a webcam are required. This program uses Zoom web conferencing software; a link to the session will be shared with participates prior to each session.
Submit (de‐identified) case(s) and present them to the group
Complete a post‐assessment survey at the end of each session
Provide requested evaluation feedback at the end of the full program.

I understand that:

Project ECHO case consultations do not create or otherwise establish a provider‐patient relationship between any teleECHO clinician and any patient whose case is being presented in a teleECHO session, and
While the case consultations and teleECHO sessions may offer recommendations regarding effective evaluation, care, and treatment options, these represent recommendations only. The patient’s treating provider retains sole responsibility for selecting and implementing the plan for evaluation, care, and treatment of the patient.

General questions about the University of New England's Project ECHO can be directed to cetl@une.edu.

ECHO- or topic-specific questions can be directed to ceph-echo@une.edu.

Sign by typing name

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Date

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M-D-Y

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