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ECHO 2027 Application

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This field is for validation purposes and should be left unchanged.
The application can take from 30 to 60 minutes to complete; however, please remember that the application does not have to be completed in one sitting. If you would like to save your application and return to it at a later time, you may do so by clicking the “Save and Continue Later” button located in the bottom left of the application. All applicants will be notified of their status no later than the week of December 21st, 2026. Thank you for your interest in the ECHO Training Program!
Background Information
Name:(Required)
First Middle Last
Address:(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please indicate if this is your work or home address:(Required)
- Work
- Home
Have you previously participated in the ENRICH or ECHO training program (DID receive CEUs)?(Required)
- Yes
- No
If yes, what year did you participate?
Have you ever participated as an auditor for ECHO (did NOT receive CEUs)?(Required)
- Yes
- No
If yes, what year did you participate?
Ethnicity:
- Hispanic / Latino
- Not Hispanic / Latino
Sex assigned at birth:
- Female
- Male
- Decline to answer
This field is hidden when viewing the form
Gender Identity:
- Male
- Female
- Transgender Male/Trans Man/FTM
- Transgender Female/Trans Woman/MTF
- Gender Queer/Gender Fluid
- Additional category
- Prefer not to respond
Please specify:
This field is hidden when viewing the form
Do you think of yourself as:
- Lesbian or gay
- Straight
- Bisexual/Pansexual
- Something else
- Don’t know
- Prefer not to respond
Race:
Check all that apply
- American Indian/Alaska Native
- Black or African American
- White
- Asian
- Native Hawaiian/Pacific Islander
- More than one race
- Prefer not to respond
- Other
Please specify:

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Contact Information:
Telephone(Required)
Please indicate if this is your work or personal number:(Required)
- Work
- Personal
Email(Required)
Secondary Email
Workplace:
Name of Institution:(Required)
Years in Profession:(Required)
Years in Oncology:(Required)
Which of the following best describes your primary job responsibility?(Required)
- Nurse Practitioner
- Oncology Nurse
- Physician
- Physician Assistant
- Psychologist
- Social Worker
- Other
Please specify:
How did you hear about ECHO?(Required)
- Supervisor or Colleague
- ECHO Website
- Previous ECHO or ENRICH Participant
- Facebook, Linkedin, Other Social Media
- Conference
- Professional Listserv
- Other
Please Specify:

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Education
Please list in reverse chronological order, starting with the most recent first.
Institution 1
Institution and Location(Required)
Degree / Certification
If applicable
Date of Completion/Graduation (Month/Year)(Required)
Field of Study(Required)
Do you have an additional educational institution to report?(Required)
- Yes
- No
Institution 2
Institution and Location
Degree / Certification
If applicable
Date of Completion/Graduation (Month/Year)
Field of Study
Do you have an additional educational institution to report?
- Yes
- No
Institution 3
Institution and Location
Degree / Certification
If applicable
Date of Completion/Graduation (Month/Year)
Field of Study
Do you have an additional educational institution to report?
- Yes
- No
Institution 4
Institution and Location
Degree / Certification
If applicable
Date of Completion/Graduation (Month/Year)
Field of Study

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Nurse/NP: Licensures or Certifications
Check all that apply:
- ANP
- ARNP
- RN
- BSN
- CNS
- CPHON
- OCN
- AOCNP
- ACONS
- CBCN
- AOCN
- CPON
- Other
Please specify:
Physician: Licensures
- MD
- DO
- Other
Please specify:
Physician Assistant: Licensures or Certifications
Check all that apply:
- PA-C
- Other
Please specify:
Psychologist: Licensures or Certifications
Check all that apply:
- Clinical Psychology
- Clinical Health Psychology
- Clinical Child Psychology
- Other
Please specify:
Social Worker: Licensures or Certifications
Check all that apply:
- LCSW
- OSW-C
- QCSW
- LSW
- C-SWHC
- MSW
- Other
Please specify:

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Practice Setting
Which of the following best describes your workplace?(Required)
- Academic Cancer Center
- Community Cancer Center
- Community Hospital
- Private Practice
- Unsure / Don't know
Does your workplace have any of the following designations?(Required)
- NCI Designated Comprehensive Cancer Center
- NCI Designated Cancer Center
- NCI Community Cancer Center Program
- No
- Unsure / Don't know
Does your institution currently have Commission on Cancer (CoC) accreditation?(Required)
- Yes
- No
- In the process of obtaining accreditation
- Unsure / Don't know
Do your patients have access to an Adolescent and Young Adult program?(Required)
- Yes
- No
- Unsure / Don't know
Is this program at the site where you are physically located?(Required)
- Yes
- No
- Unsure / Don't know
Does your institution have navigators for oncology patients?(Required)
- Yes
- No
- Unsure / Don't know
If you work in a hospital, how many beds are in your oncology unit? Please leave blank if you do not know.

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Population Served
Please indicate (or estimate) what percentage of your patients are:(Required)
Totals do not need to add up to 100%.
None 1%-25% 26%-50% 51%-75% 76%-100%
Ages 15-39
Hispanic/Latino
American Indian or Alaska Native
Black or African American
White
Asian
Native Hawaiian/Pacific Islander
Male
Female
Privately insured

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Personal Practice
Please rate your confidence in your communication skills on each of the following topics with AYA oncology patients.(Required)
1 = not at all confident, 2 = slightly confident, 3 = somewhat confident, 4 = confident, 5 = very confident
1 2 3 4 5
Impact of cancer on fertility
Fertility preservation options
Sexual intimacy concerns
Contraception
STIs
HPV vaccine
Mental/behavioral health
Social (e.g. work, school, family, friends)

Please rate how frequently you discuss each of the following topics with AYA oncology patients.(Required)

	Never	Rarely	Sometimes	Often	Always
Impact of cancer on fertility
Fertility preservation options
Sexual intimacy concerns
Contraception
STIs
HPV vaccine
Mental/behavioral health
Social (e.g. work, school, family, friends)

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Please describe your own involvement in initiatives at your workplace related to reproductive health (e.g., risk of infertility fertility preservation, contraception, sexual functioning).
Committee/task force/advisory group(Required)
Check all that apply
- Participated in
- Implemented/Led/Presented
- Evaluated
- No Involvement
Development of policies/guidelines/procedures(Required)
Check all that apply
- Participated in
- Implemented/Led/Presented
- Evaluated
- No Involvement
Development of patient education material(Required)
Check all that apply
- Participated in
- Implemented/Led/Presented
- Evaluated
- No Involvement
Staff education(Required)
Check all that apply
- Participated in
- Implemented/Led/Presented
- Evaluated
- No Involvement
Met with leadership(Required)
Check all that apply
- Participated in
- Implemented/Led/Presented
- Evaluated
- No Involvement
Shared information with professional organizations(Required)
Check all that apply
- Participated in
- Implemented/Led/Presented
- Evaluated
- No Involvement
Shared information internally at your organization(Required)
Check all that apply
- Participated in
- Implemented/Led/Presented
- Evaluated
- No Involvement
Please describe your involvement in any other reproductive health activities related to AYA oncology patients.

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Statement of Intent
The Statement of Intent serves as a deciding factor in determining your eligibility for the training. Please carefully read the instructions and include as much detail in your answer as possible.
Please describe your professional background and the goals you hope to achieve by participating in the ECHO training program. This response will be an important tool for the review committee to evaluate applicants with the greatest potential to benefit from ECHO.(Required)
500-1500 characters
Additional Comments
Time Commitment Acknowledgment(Required)
I acknowledge the time commitment for a CEU-accredited spot in the 2027 ECHO cohort, which is approximately 1-2 hours per week and to be completed within 9 weeks. If I am aware of my inability to commit to an accredited training spot, I will give notice to the training support team as soon as possible and consider taking an auditor spot instead, which is not accredited but enables me access to all web components of the training without a deadline. Further, I understand that an accredited spot, which is paid through the ECHO grant fund, cannot be refunded and used for another participant or training period in case I accept with the knowledge of not being able to finish the training in the given time period.
- I have read and understood the acknowledgement above.

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About Echo

ECHO is a web-based training program that includes psychosocial, biological, clinical, and skill building modules to help oncology health professionals communicate timely and relevant information regarding reproductive health to their adolescent and young adult (AYA) patients. This program and course materials are provided at no cost to participants.

FAQ

Click below to learn more about our innovative oncology allied health professional training program in reproductive health!

ECHO FAQs

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NYU Grossman School of Medicine

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NYU Grossman School of Medicine

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	None	1%-25%	26%-50%	51%-75%	76%-100%
Ages 15-39
Hispanic/Latino
American Indian or Alaska Native
Black or African American
White
Asian
Native Hawaiian/Pacific Islander
Male
Female
Privately insured

TESTER PAGE

ECHO 2027 Application

Step 1 of 9

Background Information

Contact Information:

Workplace:

Education

Institution 1

Institution 2

Institution 3

Institution 4

Practice Setting

Population Served

Personal Practice

Statement of Intent