2025 Rare Epi ECHO - Participant Registration Form

2025 Rare Epi ECHO - Participant Registration Form

ATTENTION - THIS REGISTRATION IS

FULL & CLOSED

If you are signing up after Jan 22, 2025 - the program is now full. We will leave the form below open. Anyone who signs up after this date will be added to a waitlist and contacted when the next program becomes available.

Thank you for your interest. You can contact Ilene Penn Miller at ilenepennmiller@gmail.com with any questions.

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Thank you for signing up as a participant for The (Not So Rare) Epilepsies Series: Bridging Genetic Diagnosis with Complex Care ECHO. The series will launch Jan. 22, 2025 at 3 PM ET and run for six 60 minute sessions every other week with one 90 minute session on February 19th. You will receive a calendar invite but the dates for your information are:

Jan 22
Feb 5
Feb 19* (90 minutes)
Mar 5
Mar 19
Apr 2

You will be asked to complete two registrations: (1) participant registration and (2) platform registration.

This is the participant form including your contact information, credentials and some background on your practice and interests.

You will receive a separate invitation to register for the iECHO Platform which is the technology we use to share calendar invites, send reminders, share agendas, disseminate materials, post surveys and more.

If you have any questions or require assistance, please contact Ilene Penn Miller at 240.205.4807 or ilenepennmiller@gmail.com.

First Name:*

Last Name:*

Credentials eg (MD, PhD):

Brief Title (e.g, Clinical Director, Children's Hospital State):*

Phone number:*

Phone

Email address:*

Practice/Organization Name:*

Practice/Organization Location:

Mailing Address - Street Address*

Mailing Address - City*

Mailing Address - State*

Select or enter value

Mailing Address - Zip Code*

What is your gender?*

Select or enter value

Please specify if selected 'Prefer to self-describe'

Do you consider yourself Hispanic/Latinx? *

Select or enter value

Which of the following best describes your race? Please check all that apply.*

Select or enter value

If selected 'Another option not listed here', please specify:

Please share information about your practice:

Please indicate your number of years in practice/profession (post most advanced training):*

Select or enter value

Which of the following best describes the setting of your practice?*

Select or enter value

Which of the following best describes where you work? (pick the best answer):*

Select or enter value

If selected 'Other', please specify:

Which one of the following best describes the type of service you provide?*

Select or enter value

If selected 'Other', please specify:

Please share information about your training:

Which of the following best describes your training?*

Select or enter value

If you selected Physician (MD, DO), which of the following best describe your career stage:*

Select or enter value

If selected 'Other', please specify:

If you selected Physician (MD, DO) which of the following best describes your practice?*

Select or enter value

Please specify, if selected 'Other'

In what areas of pediatrics are you board eligible/board certified?*

Select or enter value

Please specify, if selected 'Pediatrics Specialty':

Please specify is selected 'Other'

Are you board certified in epilepsy?*

Select or enter value

Typical work week:

During a typical complete work week, how many hours per week do you spend in direct patient care (DPC)?*

Select or enter value

During a typical complete work week, how many hours per week do you spend in resident education?*

Select or enter value

During a typical complete work week, how many hours per week do you spend in other professional activities (eg, administration, research)*

Select or enter value

During a typical complete work week, how many hours per week do you spend in rare epilepsy related activities?*

Select or enter value

Please estimate the number of patients that you see in an average month.*

Select or enter value

Please estimate the number of patients with a rare epilepsy that you see in an average month.*

Select or enter value

Approximately what percentage of your patients have:

Private Insurance*

Select or enter value

Public Insurance (Medicare, Medicaid)*

Select or enter value

No Insurance*

Select or enter value

Please estimate tell us what proportion of your patients you would estimate to be in the following racial or cultural groups. If you have no patients in a specific group, please enter a "0" in that space.

Hispanic/Latinx*

Select or enter value

American Indian or Alaska Native*

Select or enter value

Asian or Asian American*

Select or enter value

Black or African American*

Select or enter value

Native Hawaiian or Other Pacific Islander*

Select or enter value

Middle Eastern or North African*

Select or enter value

White/Caucasian*

Select or enter value

Other

Select or enter value

Other (please specify)

Please Share more information about your Interest:

Why are you interested in learning more about the rare epilepsies?*

What questions or challenges do you or your practice currently face in regard to the rare epilepsies?*

Each ECHO session will include a short lecture on a topic related to the rare epilepsies. Please list any specific topics that you are interested in learning about.*

Do you have an example of a complex/interesting case that you would be willing to share with a short case presentation (less than 5 minutes) that would serve as the focus of discussion on a future ECHO session? (Case presentations are accepted on a rolling basis. If you don’t have an idea presently, you may submit suggestions throughout the ECHO sessions to: Jeff or Ilene*

Select or enter value

How many ECHOs have you previously participated in (not including this one)?*

Select or enter value

Do you have access to the following? Check all that apply.*

Select or enter value

How did you hear about us?

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If you selected "Other," please specify:

Send me a copy of my responses

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