UW Psychiatry and Addictions Case Conference Series (UW PACC) Participant Registration Form

Welcome to UW PACC! 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 uwpacc@uw.edu with any further questions.

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PhD

PharmD

Nurse Practitioner

Physician Assistant

Student

Other, please specify

Not applicable

PCP

Provider of psychiatric services

Other, please specify

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Considering all of your clinical sites, what percentage of your practice is seriously complicated by any of the following:

(Please provide your best estimate of percentage, from 0 - 100. If none, please enter zero. We understand you may not have an exact number. An estimate is fine, and will better help us understand your needs.)

Yes

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I have not been interested.

I was never trained in residency.

I am interested but would need support to get started.

I have not been able to get the waiver.

My clinic does not support me treating addictions.

I am worried about diversion.

I am worried about being taken advantage of.

These patients are hard to deal with.

I am too busy to deal with these patients.

I do not have access to additional supportive treatment options for the patients (e.g., 12-step groups, onsite treatment groups, drug counseling)

I believe treatment should be abstinence-based only

Other, please specify

How competent do you feel with the diagnosis and management of the following:

1 (Not at all competent)

5 (Highly competent)

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Never

Sometimes

Frequently

Almost always

I'm not aware of it

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Never

Sometimes

Frequently

Almost always

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Very untrue

Untrue

Neither true nor untrue

True

Very true

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Very isolated

Somewhat isolated

Neither isolated nor connected

Somewhat connected

Very connected

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Very dissatisfied

Somewhat dissatisfied

Neither dissatisfied nor satisfied

Somewhat satisfied

Very satisfied

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Please rate each on a scale of 1 (not important) to 5 (very important)

1 (not important)

5 (very important

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Website (UW PACC)

Website (UW Dept of Psychiatry & Behavioral Sciences)

Website (other, please specify)

Colleague(s)

Media

Professional conference

Professional publication

Native Center for Alcohol Research and Education (NCARE) communication

Other, please specify

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Required format:

/^[a-z0-9-]{3}$/i

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

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/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^[a-z]{3}$/i

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])$?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

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