Program Pre-Survey v1 2010 D (6/11 - 11/05/2010)
Program Pre-Survey v1 2010 D (6/11 - 11/05/2010)
Program Pre-Survey v1 2010 D (6/11 - 11/05/2010) [1]
As a part of the educational experience, we ask all users to fill out the following pre-survey
before they complete buprenorphine training. This will allow us to better understand your current
clinical practices and needs. We appreciate your input!
Learner Information Please rate the following statement *
below averag above I consi
averag e
averag der
e
e
myself
an addi
ction s
pecialis
t
My kno My kn My kn My kn My kn
wledge owledg owledg owledg owledg
/skills e/skills e/skills e/skills e/skills
about aabout aabout aabout aabout a
ddictio ddictio ddictio ddictio ddictio
n medi n medi n medi n medi n medi
cine
cine
cine
cine
cine
are * are - are - a are - are - I
below verage above consid
averag ❍
averag er
e ❍
e ❍ myself
an addi
ction s
pecialis
t ❍
Do you treat patients? * ❍ Yes
❍ No
Survey NoteThis pre-survey includes questions about treating patients. Since you do not treat
patients, we will not include your survey responses on any questions that address this topic
when we compile survey results.
Do you currently prescribe buprenorphine? * ❍ Yes
❍ No, but I will prescribe
❍ No, and I do not have any plans to prescribe
❍ No, I cannot be given a waiver (non-physician/other)
Prescribing Buprenorphine Please rate the following
Poor Fair Avera Good Excell
ge
ent
My per My p My p My p My p My p
formanerform erform erform erform erform
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Program Pre-Survey v1 2010 D (6/11 - 11/05/2010)
Poor
Fair
Average
Good
Excellent
ce in p ance ance ance ance ance
rescrib in pres in pres in pres in pres in pres
ing bu cribing cribing cribing cribing cribing
prenor bupre bupre bupre bupre bupre
phine norphi norphi norphi norphi norphi
for
ne for ne for ne for ne for ne for
detox detox detox detox detox detox
or mai or mai or mai or mai or mai or mai
ntenan ntenan ntenan ntenan ntenan ntenan
ce trea ce trea ce trea ce trea ce trea ce trea
tment tment -tment -tment -tment -tment ❍
Poor ❍
Fair ❍Avera Good Excell
ge ❍
ent ❍
Patien
t outco Patien Patien Patien Patien Patien
mes t outco t outco t outco t outco t outco
for my mes mes mes mes mes
bupre for my for my for my for my for my
norphi bupre bupre bupre bupre bupre
ne pati norphi norphi norphi norphi norphi
ents ne pati ne pati ne pati ne pati ne pati
ents - ents - ents - ents - ents ❍
Poor ❍
Fair ❍Avera Good Excell
ge ❍
ent ❍
For every 10 opioid-dependent patients I see, I
0 pati 1-2 pa 3-4 pa 5-6 pa 7-8 pa 9-10 p
ents tients tients tients tients atients
Prescr
ibe bu Prescr Prescr Prescr Prescr Prescr Prescr
prenor ibe bu ibe bu ibe bu ibe bu ibe bu ibe bu
phine prenor prenor prenor prenor prenor prenor
to
phine phine phine phine phine phine
to - 0 to to to to to patien 1-2 pa 3-4 pa 5-6 pa 7-8 pa 9-10 p
❍
❍
❍
❍
ts ❍ tients tients
tients
tients
atients
❍
Professional Development Needs Please rate the following statement *
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Program Pre-Survey v1 2010 D (6/11 - 11/05/2010)
Str Dis
ong agr
ly D ee
isa
gre
e
Nei Agr Str
ther ee ong
Agr
ly A
ee
gre
or
e
Dis
agr
ee
My
exi My My My My My
stin exi exi exi exi exi
g cl stin stin stin stin stin
inic g cl g cl g cl g cl g cl
al p inic inic inic inic inic
ract al p al p al p al p al p
ice ract ract ract ract ract
req ice ice ice ice ice
uire req req req req req
s c uire uire uire uire uire
han s c s c s c s c s c
ge han han han han han
and ge ge ge ge ge
is and and and and and
not is is is is is
opti not not not not not
mal opti opti opti opti opti
* mal mal mal mal mal
- St - Di - N - A - St
ron sag eith gre ron
gly ree er e ❍gly
Dis ❍ Agr
Agr
agr
ee
ee ❍
ee ❍ or
Dis
agr
ee ❍
Please rate the following *
Poor
Fair
Average Good
Excellent
My compet My comp My comp My comp My comp My comp
ence in
etence in etence in etence in etence in etence in
diagnosing diagnosing diagnosing diagnosing diagnosing diagnosing
and
and
and
and
and
and
treating
treating
treating
treating
treating
treating
opioid use opioid use opioid use opioid use opioid use opioid use
disorders * disorders - disorders - disorders - disorders - disorders Poor ❍ Fair ❍
Average ❍Good ❍ Excellent ❍
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Program Pre-Survey v1 2010 D (6/11 - 11/05/2010)
Poor
Fair
Average
Good
Excellent
My compet My comp My comp My comp My comp My comp
ence in
etence in etence in etence in etence in etence in
working
working
working
working
working
working
with other with other with other with other with other with other
profession profession profession profession profession profession
als to help als to help als to help als to help als to help als to help
patients
patients
patients
patients
patients
patients
with opioid with opioid with opioid with opioid with opioid with opioid
use or
use or
use or
use or
use or
use or
misuse * misuse - misuse - misuse - misuse - misuse Poor ❍ Fair ❍
Average ❍Good ❍ Excellent ❍
Patient
outcomes
for my
substance
abuse
patients *
Patient
outcomes
for my
substance
abuse
patients Poor ❍
Patient
outcomes
for my
substance
abuse
patients Fair ❍
Patient
Patient
outcomes outcomes
for my
for my
substance substance
abuse
abuse
patients - patients Average ❍Good ❍
Patient
outcomes
for my
substance
abuse
patients Excellent ❍
Screening Practice For every 10 patients you see in your typical clinical practice, how many
patients do you *
Less than 5
6-7 patients
8-9 patients
All patients
patients
Screen for past Screen for
Screen for
Screen for
Screen for
substance use past substance past substance past substance past substance
*
use - Less than use - 6-7
use - 8-9
use - All
5 patients ❍ patients ❍
patients ❍
patients ❍
Screen for
Screen for
Screen for
Screen for
Screen for
current
current
current
current
current
substance use substance use substance use substance use substance use
*
- Less than 5 - 6-7 patients ❍
- 8-9 patients ❍
- All patients ❍
patients ❍
Screen for past Screen for
Screen for
Screen for
Screen for
opioid use *
past opioid use past opioid use past opioid use past opioid use
- Less than 5 - 6-7 patients ❍
- 8-9 patients ❍
- All patients ❍
patients ❍
Screen for
Screen for
Screen for
Screen for
Screen for
current opioid current opioid current opioid current opioid current opioid
use *
use - Less than use - 6-7
use - 8-9
use - All
5 patients ❍ patients ❍
patients ❍
patients ❍
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Program Pre-Survey v1 2010 D (6/11 - 11/05/2010)
Treatment Practice For every 10 patients you see, how many patients with ANY SUBSTANCE
(alcohol and other drugs) abuse or misuse do you *
0 pati 1-2 p 3-4 p 5-6 p 7-8 p 9-10
ents atient atient atient atient patien
s
s
s
s
ts
Provi
de tre Provi Provi Provi Provi Provi Provi
atmende tre de tre de tre de tre de tre de tre
t direc atmenatmenatmenatmenatmenatmen
tly to *t direc t direc t direc t direc t direc t direc
tly to - tly to - tly to - tly to - tly to - tly to 0 pati 1-2 p 3-4 p 5-6 p 7-8 p 9-10
ents ❍
atient atient atient atient patien
s ❍ s ❍ s ❍ s ❍ ts ❍
Refer
to
Refer Refer Refer Refer Refer Refer
other to
to
to
to
to
to
treat other other other other other other
ment treat treat treat treat treat treat
provid ment ment ment ment ment ment
ers * provid provid provid provid provid provid
ers - ers - ers - ers - ers - ers 0 pati 1-2 p 3-4 p 5-6 p 7-8 p 9-10
ents ❍
atient atient atient atient patien
s ❍ s ❍ s ❍ s ❍ ts ❍
Usuall
y stay UsuallUsuallUsuallUsuallUsuallUsuall
involv y stay y stay y stay y stay y stay y stay
ed
involv involv involv involv involv involv
with * ed
ed
ed
ed
ed
ed
with - with - with - with - with - with 0 pati 1-2 p 3-4 p 5-6 p 7-8 p 9-10
ents ❍
atient atient atient atient patien
s ❍ s ❍ s ❍ s ❍ ts ❍
For every 10 patients you see, how many patients with OPIOID abuse or misuse do you *
❍
❍
❍
❍
❍
❍
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Program Pre-Survey v1 2010 D (6/11 - 11/05/2010)
0 patients
1-2 patients 3-4 patients 5-6 patients 7-8 patients 9-10 patients
❍
❍
❍
❍
❍
❍
❍
❍
❍
❍
❍
❍
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Submit
Links:
[1] https://www.buppractice.com/presurveyB1
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