The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

Working...

Working...

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Registration

Thank you for your interest in ECHO Autism Communities Partner Launch Training. Each person who is interested in participating should complete this short survey. Upon completion, you will receive payment information (if applicable). If you have questions about this training, please contact Ramiro Mitre: ramiromitre@health.missouri.edu

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Attendance

Day 1 (2/2)

Day 2 (2/3)

Language

Date Time

Please select the date that you will be attending the ECHO Autism Communities Partner Launch Training

First Name

* must provide value

Last Name

* must provide value

Email

* must provide value

Organization name that is associated with the majority of your professional role:

* must provide value

Country:

* must provide value

Organization Address:

* must provide value

City:

* must provide value

State:

* must provide value

County:

* must provide value

Province/State/Region:

* must provide value

Zip/Postal Code:

* must provide value

Is your preferred mailing address the same as Organization Mailing Address?

* must provide value

Yes No

Preferred Mailing Address Street:

* must provide value

City:

* must provide value

State:

* must provide value

County:

* must provide value

Province/State/Region:

* must provide value

Zip/Postal Code:

* must provide value

Phone Number:

* must provide value

Cell Phone Number:

* must provide value

Organizations are required to complete partnership documents with the ECHO Institute prior to attending Partner Launch Training. Has your organization signed partnership documents with the ECHO Institute?

* must provide value

Yes

No, not yet

I don't know

Are you employed by or affiliated with an Autism Care Network Site?

* must provide value

Yes

No

If so, please tell us what site you are from.

* must provide value

Autism Center of Hospital for Special Care

Children's Hospital Los Angeles- Boone Fetter Clinic

Children's Hospital of Philadelphia (CHOP)

Cincinnati Children's Hospital Medical Center

Glenrose Rehabilitation Hospital and University of Alberta

Holland Bloorview Kids Rehabilitation Hospital

Metrohealth Medical Center; Metrohealth Autism Assessment Clinic (MAAC)

Munroe-Meyer Institute, University of Nebraska Medical Center

Nationwide Children's Hospital

Phoenix Children's Hospital

Prisma Health-Upstate

The Center for Autism & Neurodevelopmental Disorders at UC Irvine

The Center for Autism and Developmental Disorders at University of Pittsburgh Medical Center

The Lurie Center for Autism

University of Massachusetts Medical School, E.K. Shriver Center and The Center for Autism and Neurodevelopmental Disorders (CANDO)

University of Missouri - ECHO Autism Communities

University of Rochester Medical Center - Golisano Children's Hospital

University of Virginia Children's Hospital

Vanderbilt University Medical Center

Waisman Center at University of Wisconsin-Madison

Seattle Children's Hospital

Rush University Medical Center

SUNY Upstate Medical University

MaineHealth

Marcus Autism Center

Main Contact or point person for your ECHO Program or future ECHO Program:

* must provide value

Type of ECHO Program (i.e. ECHO Autism, Developmental Disabilities ECHO):

* must provide value

What is your highest level of education?

* must provide value

High School / GCE A Levels / Secondary school

Associates

Bachelors

Masters

Doctorate

Other

Please list your highest level of education

* must provide value

Did you complete your highest degree in North America?

* must provide value

Yes

No

Please list your degree(s)

* must provide value

What is your degree?

* must provide value

AND

ASN

AA/AAS/ADP

Other

What is your degree?

* must provide value

BA/BS

BS Ed

BSN

BSW

MBBS

MBchB

Other

What is your degree?

* must provide value

MS

MBA

Med

MHA

MPA

MPAS

MPH

MSMI

MSN

MSW/MSSW

MOT

MPT

Other

What is your degree?

* must provide value

DDS

DMD

DO

DPT

DNP

DNP-c

DHSc

DrPH

EdD

EDS

JD

MD

OTD

PharmD

PhD

PsyD

SJD

Other

Please list your degree(s):

* must provide value

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.

* must provide value

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

Other field:

* must provide value

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.

* must provide value

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

* must provide value

What is your role in that field?

* must provide value

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?

* must provide value

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?

* must provide value

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?

* must provide value

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?

* must provide value

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?

* must provide value

Law Student

Attorney

Guardian ad litem

Judge

Other

What is your role in that field?

* must provide value

Case worker

Clinician/Therapist/Counselor

Community Support Specialist

Provisional Clinician/Therapist/Counselor

Other

What is your role in that field?

* must provide value

Biostatistician

Quality Assurance/Compliance

Researcher/Analyst

Other

What is your role in that field?

* must provide value

Nurse

Nurse Aid

Other

What is your role in that field?

* must provide value

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?

* must provide value

Dentist

Dental Hygienist

Dental Assistant

Other

What is your role in that field?

* must provide value

Pharmacist

Pharmacy Technician

Other

Are you a(n):

Intern

Resident

Fellow

Attending

What is your role in that field?

* must provide value

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

Are you a(n):

Intern

Resident

Post-Doc/Fellow

What is your role in that field?

* must provide value

Clinical Psychologist

Counseling Psychologist

Neuropsychologist

School Psychologist

Other

What is your role in that field?

* must provide value

Case Manager/Coordinator

Clinician/Therapist/Counselor

Supervisor

Other

What is your role in that field?

* must provide value

Intern/In-training

Student - Undergraduate Study

Student - Graduate Study

Student - Post-graduate Study

Student - Medical

Other

What is your role in that field?

* must provide value

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

* must provide value

What are your credentials? (Select all that apply)

* must provide value

BCaBA

BCBA

BCBA-D

LBA

LABA

RBT

LD

OTR/L

COTA/L

PT

PTA

CCC-SLP

SLPA

Other

None

What are your credentials? (Select all that apply)

* must provide value

NCMA

RMA

RMA/CCM

MTBC

ARRT

CRT

RRT

RRT-ACCS

RRT-NPS

Other

None

What are your credentials? (Select all that apply)

* must provide value

BCaBA

BCBA

BCBA-D

LBA

LPC

LPCC

PLPC

LCMFT

LMFT

LAMSW

LBSW

LCSW

Other

None

What are your credentials? (Select all that apply)

* must provide value

BME

CCRC

CEHT

CHC

CHCP

CHES

CPHQ

CPHRM

MCHES

PCMH CCE

REHS

REHS/RS

PCMH CCE

Other

None

What are your credentials? (Select all that apply)

* must provide value

CNA

LPN

LVN

RN

Other

None

What are your credentials? (Select all that apply)

* must provide value

ACCNS

ANP

APN

APRN

APRN-BC

BC FNP

C-FNP

CNL

CNS

CPNP

CPNP-PC

CS

FNP

FNP-BC

FNP-C

NP

NP-C

MHNP

PMHNP

PHNP-CNS

PMHNP-BC

PMHS

PNP

PNP-BC

RNC-FNP

Other

None

What are your credentials? (Select all that apply)

* must provide value

RDH

DDS

DMD

Other

None

What are your credentials? (Select all that apply)

* must provide value

AAHIVP

BCACP

BCPP

BCPS

CPhT

CSP

Other

None

What are your credentials? (Select all that apply)

* must provide value

BCFM

DO

FAAFP

FAAP

FACS

FAPA

MBBS

MBchB

MD

Other

None

What are your credentials? (Select all that apply)

* must provide value

PA

PA-C

Other

None

What are your credentials? (Select all that apply)

* must provide value

ABCN

ABPP

LP

LPA

LSSP

Other

None

What are your credentials? (Select all that apply)

* must provide value

BCaBA

BCBA

BCBA-D

LBA

LPC

LPCC

PLPC

LCMFT

LMFT

LAMSW

LBSW

LCSW

Other

None

What is your area of study?

* must provide value

Please list your credentials

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