Project ECHO for ILD Registration |

First Name *

Last Name *

Email *

Re-Enter Email *

Phone Number

Field of Practice (Pulmonology, Radiology, Primary Care, etc.) *

Name of Organization / Health Center / Clinic *

Organization's City *

Organization's State/Province/Region *

Organization's Country *

How would you describe your practice? *

Rural private practice

Rural affiliated with an academic center

Urban / suburban private practice

Urban / suburban affiliated with an academic center

Other (please explain):

How would you describe your practice? Other (please explain):

Does your institution have a dedicated ILD clinic that holds an ILD multidisciplinary discussion (MDD) at least monthly? *

Yes

How did you learn about Project ECHO for ILD? *

How did you learn about Project ECHO for ILD? Other

What interests you in joining Project ECHO for ILD? (Please check all that apply) *

To become a well-trained local provider for patients with ILD

To diagnose patients with ILD

To screen and refer patients with ILD to specialists for treatment

To manage and treat patients with ILD using best practice therapies with the support of Project ECHO for ILD

To become local expert in ILD in my community, and to provide consultation to other community providers in the care of patients with ILD

To continue providing care for patients with ILD in the future, with regular participation in Project ECHO for ILD

To continue providing care for patients with ILD in the future, without regular participation in Project ECHO for ILD

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Project ECHO for ILD Registration