Now M-D-Y H:M
First name
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Last name
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E-mail
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Phone number
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Include Area Code
Job title
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Please select your highest credential
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BA BS BSN BSW CGC CHES CNA CNNP CNS CRNP DC DO DNP DPT FNP LCGC LCSW LSW MD MOT MPH MSN MSW PA-C PhD PT RD RN Other Not applicable
This ECHO program offers continuing education credit. Your credits can be claimed using the certificates that are automatically generated after completing session evaluations. Please type the credentials you would like to appear in your CE certificates for the duration of this ECHO program.
If you do not have any credentials to list, please leave this question blank.
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i.e. MD, PhD, MPH, RN, BSN
Are you in a position of leadership?
Yes
No
If yes, please tell us more about your position.
What is your area of practice?
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Primary care
Specialty care
Non-clinical
Primary care
Specialty care
Non-clinical
Specialty or area of practice
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Addiction/SUD Adolescent Medicine Cardiology Community Health Dentistry Dermatology Education Emergency Medicine Family Medicine Gastroenterology Geriatrics Hospitalist Immunology Infectious Disease Internal Medicine LGBTQI+ Health Neurology Obstetrics & Gynecology Oncology Pain Medicine Palliative Care Pediatrics Pharmacology Physical Medicine and Rehabilitation Primary Care Psychiatry/psychology Surgery Telehealth Other
If other, please list your specialty
Workplace, facility, clinic, medical center, or organization name
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Do you practice in a primarily rural or urban setting?
Rural
Urban
Is your clinic a Federally Qualified Health Center?
Yes
No
Do you work in a medically underserved area?
Yes
No
Unsure
Country
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United States
Other
If other, what country?
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Address 1
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State/Territory
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Alabama Alaska American Samoa Arizona Arkansas 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 Utah Vermont Virginia U.S. Virgin Islands Washington West Virginia Wisconsin Wyoming
County
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Adams Allegheny (U) Armstrong Beaver (U) Bedford Berks (U) Blair Bradford Bucks (U) Butler Cambria Cameron Carbon Centre Chester (U) Clarion Clearfield Clinton Columbia Crawford Cumberland (U) Dauphin (U) Delaware (U) Elk Erie (U) Fayette Franklin Forest Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna (U) Lancaster (U) Lawrence Lebanon (U) Lehigh (U) Luzerne (U) Lycoming McKean Mercer Mifflin Monroe Montgomery (U) Montour Northampton (U) Northumberland Perry Philadelphia (U) Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland (U) Wyoming York (U)
Zip code
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Is the mailing address above your personal address or your work address?
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Personal address
Work address
Other
Personal address
Work address
Other
Please indicate other address type
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Are you a Penn State Health or Penn State College of Medicine employee?
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Yes
No
If yes, what department?
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If yes, what is your Penn State mailcode?
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I am a provider who sees patients.
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True
False
Approximately how many patients are under your care?
Have you seen any patients with symptoms related to environmental exposures?
Yes
No
Approximately, how many patients have you seen in the last year, with symptoms that may be related to the environment (physical or mental symptoms)?
Please indicate the symptoms you have seen in these patients.Select all that apply
Please specify 'other' symptoms.
Do you have patients sharing concerns about environmental exposures both current and future?Examples: neighboring farm with pesticides, heat waves, or flooding etc.
Yes
No
Have you ever conducted an Exposure History or an Environmental Health History with your patients?
An environmental health history contains questions regarding the home and surrounding environment(s) of the patient and can include questions pertaining to the location of the house; the house and drinking water supply, and changes in air quality. Questions around potential exposure setting can include proximity to industrial and hazardous sites and recreational and/or school environments.
Yes- I routinely do this with my patients
Sometimes-I do this when indicated or a need arises
No-I have not done this with my patients
Yes- I routinely do this with my patients
Sometimes-I do this when indicated or a need arises
No-I have not done this with my patients
Do you use a standard form?
i.e. one provided by the CDC or other health organization?
Yes
No
Not sure
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Do you routinely ask your patients about: Select all that apply
Please list other environmental factors you ask your patients.
Do you routinely ask about any potential environmental hazard that may be related to the patient's occupation?
Yes
No
Not sure
Do you treat patients whose occupations may have environmental exposures?
For example: farm workers, cleaners, miners, factory workers, etc.
Yes
No
Not sure
In the past year, have you received questions from your patients about how the environment might impact their health?
For example: wildfire air alerts, boil water orders, heat advisories.
Yes
No
Not sure
IF YES, please list the topics your patients are asking about
How prepared do you feel to respond to patient questions about how the environment and/or climate change is impacting their health?
* must provide value
Unprepared
Slightly prepared
Somewhat prepared
Very prepared
Unprepared
Slightly prepared
Somewhat prepared
Very prepared
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
What environmental health issues are most concerning to YOU?
Select all that apply
Please share your other concerns.
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
What environmental health issues are most concerning to YOUR PATIENTS?
Select all that apply
Please share your other concerns.
How well do you feel your health system is connected to local community organizations/resources?
Not connected well
Slightly connected
Somewhat connected
Very connected
Not connected well
Slightly connected
Somewhat connected
Very connected
What skills do you feel clinicians need to improve upon (or acquire) to become climate-informed and climate-prepared clinicians?
What changes are needed where you work to become a climate-resilient health system?
How important is the issue of global warming to you personally?
Not at all important
Not too important
Somewhat important
Very important
Extremely important
Not at all important
Not too important
Somewhat important
Very important
Extremely important
How worried are you about global warming?
Not at all worried
Not very worried
Somewhat worried
Very worried
Not at all worried
Not very worried
Somewhat worried
Very worried
How much do you think global warming will harm you personally?
Not at all
Only a little
A moderate amount
A great deal
Don't know
Not at all
Only a little
A moderate amount
A great deal
Don't know
How much do you think global warming will harm future generations of people?
Not at all
Only a little
A moderate amount
A great deal
Don't know
Not at all
Only a little
A moderate amount
A great deal
Don't know
Which topics related to environmental health are you most interested in learning more about during this ECHO series?
What additional topics are you interested in learning more about through ECHO?
I heard about Project ECHO from
Colleague
Email
Event
Grand rounds
Penn State newsletter
Phone call
Postcard
Publication
Social media
Web search
Other
Colleague
Email
Event
Grand rounds
Penn State newsletter
Phone call
Postcard
Publication
Social media
Web search
Other
If other, please describe
Have you participated in Project ECHO before?
Yes No
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