AAP PEHSU ECHO Registration

The American Academy of Pediatrics (AAP) is implementing a national Project ECHO® (Extension for Community Healthcare Outcomes) for reproductive and pediatric environmental health, funded (in part) by the cooperative agreement FAIN: U61TS000237-04 from the Agency for Toxic Substances and Disease Registry (ATSDR).

The AAP PEHSU ECHO serves as a forum for health care professionals to learn how to identify, diagnose and treat environmentally-related health conditions in children. This project uses the ECHO (Extension for Community Healthcare Outcomes) model, a tele-mentoring hub and spoke platform that leverages technology to bring together specialty care providers at academic medical centers (hub) and primary care providers in local communities (spokes). The AAP PEHSU ECHO builds a bi-directional virtual knowledge network whereby participants learn from experts and each other, gaining access to evidence-based and capacity-building resources. Each ECHO session includes a brief presentation by a national expert, followed by in-depth, practice-based presentations for discussion, problem-solving guidance and recommendations. All attendees are invited to share and actively participate.

Sessions will occur beginning in January 2018 and will last one hour. The frequency of the sessions is to be determined.

If you are interested in registering for the AAP PEHSU ECHO clinics, please complete the details below. AAP staff will follow up with you with further details.

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* 1. Name (first, last, credentials)

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* 2. Which of the following best describes your training?

Doctor (MD, DO)

Advanced Clinical Provider (PA, NP)

Social Worker

Nurse

Other (please specify)

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* 3. Email Address

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* 4. City, State

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* 5. Clinics will be offered on consistent days and times and will last one hour. Please select all timeframes that would work best for you. (check all that apply)

Monday morning (8am-12pm CST)

Monday afternoon (12pm-5pm CST)

Tuesday morning (8am-12pm CST)

Tuesday afternoon (12pm-5pm CST)

Wednesday morning (8am-12pm CST)

Wednesday afternoon (12pm-5pmCST)

Thursday morning (8am-12pm CST)

Thursday afternoon (12pm-5pm CST)

Friday morning (8am-12pm CST)

Friday afternoon (12pm-5pm CST)

Week day morning before clinic starts (6-8am CST)

Week day evening after clinic ends (5-8pm CST)

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* 6. Which of the following describes your patient population?

Children only

Adults only

Children and adults

Pregnant women

I do not treat/see patients

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* 7. Roughly how many patients do you see on a monthly basis who have the following:

	None	1-9	10-19	20 or more	Not applicable, I don't see patients
Adolescent occupational physical exam	Adolescent occupational physical exam None	Adolescent occupational physical exam 1-9	Adolescent occupational physical exam 10-19	Adolescent occupational physical exam 20 or more	Adolescent occupational physical exam Not applicable, I don't see patients
Asthma	Asthma None	Asthma 1-9	Asthma 10-19	Asthma 20 or more	Asthma Not applicable, I don't see patients
Eczema	Eczema None	Eczema 1-9	Eczema 10-19	Eczema 20 or more	Eczema Not applicable, I don't see patients
Food allergy (including dairy)	Food allergy (including dairy) None	Food allergy (including dairy) 1-9	Food allergy (including dairy) 10-19	Food allergy (including dairy) 20 or more	Food allergy (including dairy) Not applicable, I don't see patients
Food safety concerns (e.g. arsenic in rice, mercury in fish)	Food safety concerns (e.g. arsenic in rice, mercury in fish) None	Food safety concerns (e.g. arsenic in rice, mercury in fish) 1-9	Food safety concerns (e.g. arsenic in rice, mercury in fish) 10-19	Food safety concerns (e.g. arsenic in rice, mercury in fish) 20 or more	Food safety concerns (e.g. arsenic in rice, mercury in fish) Not applicable, I don't see patients
Developmental disabilities (including autism)	Developmental disabilities (including autism) None	Developmental disabilities (including autism) 1-9	Developmental disabilities (including autism) 10-19	Developmental disabilities (including autism) 20 or more	Developmental disabilities (including autism) Not applicable, I don't see patients
Lead poisoning	Lead poisoning None	Lead poisoning 1-9	Lead poisoning 10-19	Lead poisoning 20 or more	Lead poisoning Not applicable, I don't see patients
Obesity	Obesity None	Obesity 1-9	Obesity 10-19	Obesity 20 or more	Obesity Not applicable, I don't see patients
Secondhand tobacco smoke exposure (including e-cigarettes)	Secondhand tobacco smoke exposure (including e-cigarettes) None	Secondhand tobacco smoke exposure (including e-cigarettes) 1-9	Secondhand tobacco smoke exposure (including e-cigarettes) 10-19	Secondhand tobacco smoke exposure (including e-cigarettes) 20 or more	Secondhand tobacco smoke exposure (including e-cigarettes) Not applicable, I don't see patients
Second hand marijuana smoke / inadvertent marijuana exposure	Second hand marijuana smoke / inadvertent marijuana exposure None	Second hand marijuana smoke / inadvertent marijuana exposure 1-9	Second hand marijuana smoke / inadvertent marijuana exposure 10-19	Second hand marijuana smoke / inadvertent marijuana exposure 20 or more	Second hand marijuana smoke / inadvertent marijuana exposure Not applicable, I don't see patients
Skin conditions (e.g. rashes)	Skin conditions (e.g. rashes) None	Skin conditions (e.g. rashes) 1-9	Skin conditions (e.g. rashes) 10-19	Skin conditions (e.g. rashes) 20 or more	Skin conditions (e.g. rashes) Not applicable, I don't see patients
School-related health problems	School-related health problems None	School-related health problems 1-9	School-related health problems 10-19	School-related health problems 20 or more	School-related health problems Not applicable, I don't see patients

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* 8. How often would you be likely to attend a 1-hour ECHO clinic session?

Once per week

Twice per month (biweekly)

Once per month

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* 1. Name (first, last, credentials)

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* 2. Which of the following best describes your training?

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* 3. Email Address

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* 4. City, State

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* 5. Clinics will be offered on consistent days and times and will last one hour. Please select all timeframes that would work best for you. (check all that apply)

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* 6. Which of the following describes your patient population?

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* 7. Roughly how many patients do you see on a monthly basis who have the following:

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* 8. How often would you be likely to attend a 1-hour ECHO clinic session?

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* 9. Please list any environmentally-related topics and health conditions about which you would be interested in learning more: