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

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Required format:

IZamGxDV6ordpuBnpuGK89cojMR5VjbFrFGhm2t7jWPcFae3Jnd2AGTBRwSMwsiV9cVc6JCp9Y5iWACzZwKBSQrBqfpL5I84MTunDwzqmQD2uxMY7zp

Registration

To register for Cal-MAP Project ECHO: Pediatric Mental Health Advanced Series 2024 (eligible for CME and American Board of Pediatrics MOC Part 2 credit), please complete the survey below.

Thank you!

Email address

* must provide value

First Name

* must provide value

Last Name

* must provide value

Date of Birth (M/D/Y)

* must provide value

M-D-Y

American Board of Pediatrics ID number: Please list your American Board of Pediatrics (ABP) ID number. Please note: It's vital for us to have an accurate specialty board ID number to award you with MOC credit.

If you do not wish to obtain ABP MOC Part 2 credit, you may leave this blank. Please note that we are only able to provide American Board of Pediatrics MOC credit, and not for other specialty boards. Thank you.

Employer or Name of Practice

* must provide value

Primary Work/Practice Address
(Street, City, State, ZIP)

* must provide value

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Primary work location: County name

* must provide value

Phone number

* must provide value

Profession/Credential(s): Please select all that apply

* must provide value

Physician (MD/DO)

Nurse Practitioner (NP)

Physician Assistant (PA)

Psychologist (PhD/PsyD)

Social Worker (LCSW, MSW, ASW)

Family Therapist (MFT)

Nurse (RN)

Other Allied Health Professional (OT, PT, SLP, etc)

Other

Medical Specialty: Please select all that apply. (If you are not a medical provider, select "Not applicable").

* must provide value

Pediatrics

Family Medicine

Psychiatry

Obstetrics/Gynecology

Internal Medicine

Other

Not applicable

Number of years out of residency training (or years in independent practice)

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35+

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Gender (choose all that apply)

* must provide value

Female

Male

Trans-gender

Non-binary/non-conforming

Research has shown that having a provider whose race/ethnicity matches that of their patients can lead to better clinical outcomes. Cal-MAP is collecting this data to help track whether its trainings are reaching a diverse pool of providers.

Ethnicity

Hispanic or Latino

NOT Hispanic or Latino

Unknown / Not Reported

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Race

All Cal-MAP ECHO participants should sign up to share a case related to the ECHO topic of the day. Please choose at least 2 dates/topics to share a case with the group.

* must provide value

1/10/2024: Eating Disorders

2/14/24: Disruptive Behavior

3/13/2024: Trauma

4/10/2024: Early Childhood Mental Health

5/8/2024: Sleep

6/12/2024: Substance Use

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