Prerequisites  In order to apply for a tool kit please ensure you are registered for the regular ECHO session.  You will also be required to sign the Statement of Collaboration for the regular ECHO session.   

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* 1. First  Name

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* 2. Last  Name

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* 3. Email Address

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* 4. Profession

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* 5. Organization

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* 6. Do you have an interprofessional wound care team in your organization?

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* 7. In a year, how many leg/foot wound care patients do you see?

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* 8. In a year how many NEW  leg/foot wound care patients do you see?

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* 9. In a year, how many patients that require footcare/footwear do you see?

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* 10. Do you have any prior wound care education/training ? 
(Select all that apply)

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* 11. If accepted to receive a tool kit, you will be required to sign the tool kit agreement that address's privacy, confidentiality and commitment as an ECHO partner and tool kit recipients.

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* 12. Any other comments on your need to deliver optimal leg and foot wound care?

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