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First Name
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Last Name
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Email
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Please confirm the date that you will be attending Intro to ECHO Autism
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November 14, 2024 | 9:30 - 11:00 am CST
December 18, 2024 | 9:30 - 11:00 am CST
January 15, 2025 | 9:30 - 11:00 am CST
February 13, 2025 | 9:30 - 11:00 am CST
March 19, 2025 | 9:30 - 11:00 am CDT
April 16. 2025 | 9:30 - 11:00 am CDT
May 8, 2025 | 9:30 - 11:00 am CDT
June 18, 2025 | 9:30 - 11:00 am CDT
Organization name that is associated with the majority of your professional role:
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City:
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State:
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Alabama Alaska Arizona Arkansas American Samoa California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Province/State/Region:
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Country:
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Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (the Democratic Republic of the) Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Cote d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands [Malvinas] Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati N. Korea S. Korea Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova (the Republic of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of North Macedonia Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syrian Arab Republic Taiwan (Province of China) Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States of America United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Aland Islands
What is your highest completed level of education?
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High School / GCE A Levels / Secondary school
Associates
Bachelors
Masters
Licentiate
Doctorate
Other
Please list your highest level of education
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Did you complete your highest degree in North America?
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Yes
No
What is your degree?
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What is your degree?
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What is your degree?
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What is your degree?
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Please list your degree(s):
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Which of these fields best categorizes the field you work in?We all have multiple roles and identities. Please consider your role (and field) as it relates to participation in this specific ECHO.
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Law
Therapeutic companion
Anesthesiology
Art therapy
Health assistant
School assistant
Audiology
Biology
Biochemistry
Cardiology
Surgery
Dermatology
Education
Endocrinology
Nursing
Pharmacy
Physiatry
Physiotherapy
Phonoaudiology / Logopedia / Speech Language Pathology
Gastroenterology
Genetics
Infectology
Engineering
Immunology
Kinesiology
General medicine
Music therapy
Neonatology
Neurology / Child neurology
Neuropsychology
Neurorehabilitation
Nutrition
Odontology
Ophthalmology
Oncology
Optometry
Otorhinolaryngology
Pediatrics
Psychology
Psychomotricity
School psychology
Psychiatry
Chiropractic
Radiology
Occupational Therapy
Social work
Traumatology
Shadow-teaching
Special teaching
Self advocate / family advocate
Other
Please list your credentials (in some countries, certain jobs require specific qualifications, such as RN, BCBA, LCSW, etc.)
Which of these fields best categorizes the field you work in?We all have multiple roles and identities. Please consider your role (and field) as it relates to participation in this specific ECHO.
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Clinical intervention (ABA, OT, SLP, etc)
Clinical Health/Allied Health
Community Support/Resource Navigation/Community Resource
Education
Family/Self-Advocate
Law
Mental Health
Non-Clinical Health/Public Health/Research
Nursing
Nurse Practitioner
Oral Health
Pharmacy
Physician
Physician Assistant
Psychologist
Social Work
Student (Undergrad, Graduate, Medical, etc...)
Business
Other
Please list your field of work
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What is your role in that field?
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Behavioral Implementer
Behavioral Specialist
Dietician
Occupational Therapist
Occupational Therapist Assistant
Physical Therapist
Physical Therapist Assistant
Speech Language Pathologist
Speech Language Pathologist - Assistant
Other
What is your role in that field?
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Clinical Lab Worker/Med Technologist
Electroneurodiagnostic Technologist
EMT/Paramedic
Exercise Science Professional (trainer, physiologist)
Genetic Counselor/Genetic Assistants
Kinesiotherapist
Lactation Consultant
Magnetic Resonance Technologist (MRI)
Medical Assistant
Music Therapist
Phlebotomist
Radiologist
Respiratory Therapist
Other
What is your role in that field?
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Certified Peer Mentor
Community Health Worker
Family Advocate
Family/Caregiver/Patient Navigator
Program Coordinator/Manager/Supervisor
Resource Specialist/Resource Navigator
Support Coordinator/Service Coordinator
Other
What is your role in that field?
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Certified Peer Mentor
Higher Education (non-medical): Professor/Assistant Prof/Associate Prof/Adjunct Prof/Emeritus, etc.
Para Professional
School Administrator
School Principal
School Teacher
Other
What is your role in that field?
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Caregiver
Certified Peer Mentor
Extended Family /Caregiver Support
Family Advocate
Foster Parent
Grandparent
Guardian
Kinship Foster Parent
Parent
Parent Partner
Self-Advocate
Other
What is your role in that field?
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Law Student
Attorney
Guardian ad litem
Judge
Other
What is your role in that field?
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Case worker
Clinician/Therapist/Counselor
Community Support Specialist
Provisional Clinician/Therapist/Counselor
Other
What is your role in that field?
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Biostatistician
Quality Assurance/Compliance
Researcher/Analyst
Other
What is your role in that field?
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Nurse
Nurse Aid
Other
What is your role in that field?
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Family Medicine
Internal Medicine - General
Internal Medicine - Specialist
Internal Medicine - Pediatrics (Med-Peds)
Neurology
Nurse Practitioner
Pediatrics - General
Pediatrics - Specialist
Physician Assistant
Psychiatry - Child and Adolescent
Psychiatry - General
Other
What is your role in that field?
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Dentist
Dental Hygienist
Dental Assistant
Other
What is your role in that field?
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Pharmacist
Pharmacy Technician
Other
Intern
Resident
Fellow
Attending
What is your role in that field?
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Family Medicine
Internal Medicine - General
Internal Medicine - Specialist
Internal Medicine - Pediatrics (Med-Peds)
Neurology
Pediatrics - General
Pediatrics - Specialist
Psychiatry - Child and Adolescent
Psychiatry - General
Other
Intern
Resident
Post-Doc/Fellow
What is your role in that field?
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Clinical Psychologist
Counseling Psychologist
Neuropsychologist
School Psychologist
Other
What is your role in that field?
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Case Manager/Coordinator
Clinician/Therapist/Counselor
Supervisor
Other
What is your role in that field?
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Intern/In-training
Student - Undergraduate Study
Student - Graduate Study
Student - Post-graduate Study
Student - Medical
Other
What is your role in that field?
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Chief Financial Officer
Chief Operating Officer
Compliance Manager
Risk Manager
Quality Assurance Coordinator
Chief Quality Officer
Data Analyst
Facilities Manager
Other
Please list your role
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What are your credentials? (Select all that apply)
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What is your area of study?
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Please list your credentials
Please share what drives your interest in starting an ECHO program?
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ECHO Autism Communities minimum data set © 2022; ECHO Autism Communities. All rights reserved