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 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
No
What sex were you assigned at birth on your original birth certificate?
Male
Female
Do you currently describe yourself as male, female or transgender?
Male
Female
Transgender
None of these
How many years have you been in practice?
What is your clinical degree (check all that apply):
* must provide value
MD
DO
PhD
PharmD
Nurse Practitioner
Physician Assistant
Student
Other, please specify
Not applicable
Please specify your degree:
What is your primary function:
PCP
Provider of psychiatric services
Other, please specify
Please specify your primary function:
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.)
Indicate % by entering a number between 0 and 100.
Indicate % by entering a number between 0 and 100.
Indicate % by entering a number between 0 and 100.
Do you currently have a DATA 2000 waiver to prescribe buprenorphine for the treatment of opioid use disorders?
Yes
No
How many patients do you treat for Opioid Use Disorders with buprenorphine/naltrexone (NX)?
How many patients do you treat for Opioid Use Disorders with naltrexone (NX) only?
What have been barriers for you to treat Opioid Use Disorders with buprenorhpine? (Check all that apply.)
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
What are your other barriers to using buprenorphine for Opioid Use Disorders?
How competent do you feel with the diagnosis and management of the following:
Never
Sometimes
Frequently
Almost always
I'm not aware of it
How often do you use urine drug testing?
Never
Sometimes
Frequently
Almost always
Working in my practice has allowed me to experience joy in my work:
Very untrue
Untrue
Neither true nor untrue
True
Very true
Do you feel isolated from or connected to the general medical community?
Very isolated
Somewhat isolated
Neither isolated nor connected
Somewhat connected
Very connected
Do you feel satisfied with the available mental health resources in your community?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied
Please rate each on a scale of 1 (not important) to 5 (very important)
Please share your other reason(s) for participating:
How did you learn about UW PACC? Please check all that apply:
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
Please specify how you learned about UW PACC:
What topics would you like to see covered in this series?
