Prescribers

Surgeon General’s Pledge to Stem the Opioid Epidemic

SSA_OSG_Opioid_Attachment 1_Final

Prescribers

OMB: 0990-0448

Document [docx]
Download: docx | pdf

Information to be collected

Name*

Zip code*

Email address*

Profession (Select one)*

Healthcare professional student

Doctor (M.D. or D.O.)

Nurse/Nurse Practitioner

Resident

Physician Assistant

Physical Therapist/Occupational Therapist

Dentist

Pharmacist

Other



Specialty (Select one)

Family Medicine

Pediatrics

OB/Gynecology

ENT/Otolaryngology

Pathology

Emergency Medicine

Preventive Medicine

Psychiatry

Radiology

Anesthesiology

Dermatology

Neurology

Pain Medicine

Physical Medicine & Rehab


Internal Medicine

Internal Medicine (subspecialty)

Nephrology

Cardiology

Rheumatology

Neurology

Hematology/Oncology

Infectious Disease

GI

Geriatrics

Other

Surgery

Surgery (subspecialty)

Plastic

Thoracic

Urology

Ophthalmology

Orthopedic

Other




Other





Open text questions

Question 1: How has the prescription opioid crisis impacted you, your practice, or your patients? (open text box)

Question 2: What have you found to be effective strategies to address the prescription opioid crisis in your clinic and/or community? (open text box)

*Required information

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHarris Qureshi
File Modified0000-00-00
File Created2021-01-23

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