Please complete this form, and we will contact you based on your interest for any upcoming courses . The traditional in-person 2-day point-of-care ultrasound course is hosted 1-2 times per year.
First Name:
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Last Name:
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Email Address:
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Work Phone Number:
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Cell Phone Number:
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Address for mailing course-related materials and supplies:
Address Line 1: Address Line 2:
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Address Line 1:
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City:
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State:
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Zip Code:
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What course format are you interested in participating in?
Virtual course only
In-person course only
Either a virtual or in-person course
What time zone do you anticipate being in during the virtual point-of-care ultrasound course?
Eastern
Central
Mountain
Pacific
Other
Will you have personal access to an ultrasound machine for the weekly 2-hour hands-on scanning sessions (4 sessions total)?Note : If your ultrasound machine is used for clinical care or shared with others, you will need to ensure it is available for the 2-hour tele-ultrasound sessions. Alternatively, if you are unsure about securing an ultrasound machine, select "no" and we will make arrangements to get you a loaned ultrasound machine from one of the manufacturers.
Yes
No
I don't know
Please provide the make and model of the ultrasound machine/device you will use during the course:
What type of probes does your ultrasound machine have that you will have available during the course? (select all)
If you are unsure about having reliable access to an ultrasound machine, do you prefer an ultrasound machine be loaned to you?
Yes No
Do you have a preferred make and model if an ultrasound machine can be loaned to you?
Yes No
Please provide the preferred make and model for an ultrasound machine:
The virtual hands-on sessions are conducted using tele-ultrasound software over the internet. Will you have reliable, high-speed internet access during the hands-on scanning sessions?
Yes
No
I don't know
Will you have access to a laptop or desktop computer with both audio and video capabilities for the hands-on scanning sessions?
A computer connected to the internet is needed for the tele-ultrasound sessions.
Yes, both audio and video
Yes, only audio
No, neither audio nor video
I don't know
For the course, you will need a live human model to practice scanning. In past virtual courses, participants have used a colleague also enrolled in the course ("buddy scanning"), family member, friend, staff member, or patient. Will you have access to a relatively thin human model (recommend BMI< 24) for all hands-on scanning sessions (2-hour scanning sessions weekly for 4 weeks)? Note: different people can be used as models during the course, but you must have a live model available to practice hands-on scanning.
Yes
No
I don't know
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Which of the following video conferencing platforms have you used before? [mark all that apply ]
Other - video conferencing:
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 have experience with any of the following teleultrasound technologies? [mark all that apply ]
For a live in-person course held in San Antonio, will you need hotel accommodations during the course?
Yes
No
I don't know
How many hotel rooms do you anticipate needing?
1
2
3
4
5
6
7
8
9
10
Would you be interested in participating in group activities unrelated to the CME course, such as tours or dinners?
Yes
No
I don't know
If the live in-person course gets canceled due to Covid-19, would you be interested in the virtual course option?
Yes
No - I would prefer to apply the funds toward a future in-person course
No - I would prefer a full or partial refund of the registration fee
Other
Other - cancellation option:
Gender:
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Female Male
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 > 81
Years in Practice:
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 >55
I am a:
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What do you consider your primary specialty?
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Allergy/Immunology Anesthesiology Cardiology Critical Care Dermatology Emergency Medicine Endocrinology Family Medicine Gastroenterology General Surgery Hospital Medicine Internal Medicine Neonatology Nephrology Neurology Obstetrics/Gynecology Ophthalmology Otolaryngology Pathology Pediatrics Physical Medicine and Rehabilitation Pulmonary Pulmonary/Critical Care Radiology Rheumatology Surgery - Colorectal Surgery - General Surgery - Neurological Surgery- Orthopedic Surgery - Thoracic Surgery - Trauma Surgery - Vascular Urology Other
Other - primary specialty:
Which of the following best describes the frequency of your current use of point-of-care ultrasound (POCUS) in your clinical practice?
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I do not use POCUS currently.
I might use POCUS a few times per YEAR.
I typically use POCUS a few times per MONTH.
I use POCUS routinely, at least a few times per WEEK.
I use POCUS daily, often several times per DAY.
Which of the following best describes your level of comfort with use of point-of-care ultrasound (POCUS)?
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Novice - "I do not feel comfortable using POCUS at all."
Some experience - "I feel comfortable with only a few POCUS applications."
Experienced - "I feel comfortable with several POCUS applications."
Proficient - "I feel very comfortable using POCUS with all applications relevant to my specialty."
In the past year, have you directly supervised or taught medical students, residents, physicians assistants and/or other similar trainees?
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Yes No
If yes, which of the following have you directly supervised or trained? (Select all that apply.)
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If you answered "other" to the above, please describe:
What are the primary skills or knowledge that you would like to gain by participating in this workshop? Please describe:
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Would you like to be added to our email list for future course opportunities?
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Yes No
Please press "Submit" after you have completed the form.
Thank you!