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

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:

2Sfk2WDuGUmJ3KZ3LuzQjbmd99KQTRFhN3zjrUbypDChWTvhnHNsyoGiWnX

Participant Registration Form TBI-BH ECHO

UW Traumatic Brain Injury - Behavioral Health ECHO (TBI-BH ECHO)

Participant Registration Form

Welcome to TBI-BH ECHO! To help us better understand who is participating in this program and their needs, we ask that everyone listening in or presenting cases complete this one-time registration form. After the form is submitted, you will receive an email with further instructions about how to participate.

We are glad you will be joining us! Please email us at tbi-bh@uw.edu with any further questions.

First Name:

* must provide value

Last Name:

* must provide value

Email:

* must provide value

Confirm Email:

* must provide value

The emails do not match. Please check and re-enter in the fields above.

Clinic/Facility Name (please tell us about the one where you spend the most time):

* must provide value

Clinic/Facility Address:

* must provide value

Clinic/Facility City:

* must provide value

Clinic/Facility State:

Clinic/Facility Zip Code:

* must provide value

Please list all counties where you practice:

Approximately how many patients are in your practice:

Number of clinicians in your practice:

Now, please tell us a little about yourself.

Which of the following choices best describes your race? Select all that apply.

White

Black/ African American

American Indian/Alaska Native

Asian

Hawaiian/ Pacific Islander

Other

What other race do you consider yourself?

Do you consider yourself Hispanic or Latino?

Yes

Participant Registration Form TBI-BH ECHO

UW Traumatic Brain Injury - Behavioral Health ECHO (TBI-BH ECHO)

You have selected an option that triggers this survey to end right now.