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:

pN2GaYHoIePjhiqnYWBLSTDDG8tzpZds5yqd3qjuFiyx8sn3j38m7WyAYyRME9k7qYSCpHBa

Texas Developmental Screening and Surveillance Extension for Community Healthcare Outcomes (Tx DSS ECHO) Case Presentation Form

Case Presentation Form

Thank you for your interest in sharing a case with our learning community. Please complete the following survey to help provide some important information about the case.

After you submit your form, a member of our team will be in touch to confirm session details. We ask that submitters be prepared to briefly present their case to our learning community during the live ECHO sessions. This presentation is brief (~5-8 minutes) and is followed by group discussion to identify shared challenges and provide strategies for next steps.

Submission Site:

* must provide value

Submission Date:

* must provide value

M-D-Y

Submitter Name:

* must provide value

Submitter Title:

* must provide value

Submitter email:

* must provide value

Age of the Child (months):

* must provide value

Sex of the Child:

* must provide value

Male

Female

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PLEASE NOTE that Project ECHO case consultations do not create or otherwise establish a relationship between any of the Tx DSS ECHO experts or Tx DSS ECHO staff and any participant whose case is being presented in a Tx DSS ECHO setting. Always use ECHO ID# when presenting a case. Sharing a child's name, initials or other identifying information violates HIPAA privacy laws.

a. Relevant background (include here child history, any diagnoses, pertinent family information):

* must provide value

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b. Challenges you are facing (include relevant behavior):

* must provide value

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c. Thoughts about the case (please share your initial thinking and uncertainties about the case):

* must provide value

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d. Child's existing strength and resources:

* must provide value

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e. Briefly list any strategies, interventions, or other actions you have tried:

* must provide value

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Yes

Pediatrician/ Medical Provider

* must provide value

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Home Visiting Program (Parents as Teachers, Nurse Family Partners, etc.)

* must provide value

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Child Protective Services

* must provide value

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Early Childhood Intervention

* must provide value

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Specialist (OT, PT, Speech)

* must provide value

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School District

* must provide value

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Basic Needs for Family

* must provide value

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Mental or Behavioral Health

* must provide value

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Help Me Grow or other Child Development Program/Non-profit

* must provide value

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Other

* must provide value

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Other

Questions/concerns you would like addressed during the ECHO session:

* must provide value

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Would you like to share an update of this case in the future?

* must provide value

Yes

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

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.