Form OMB Number 1117-00 OMB Number 1117-00 Prescription Monitoring Program Questionnaire

OMB 1117-0037 Approval Expires 01/31/2006

Instructions for Filling Out

the Prescription Monitoring Program Questionnaire

Completion of this questionnaire is voluntary. If you choose to do so, please complete all applicable questions on the questionnaire. Return the completed survey to DEA by [insert date]. Completed surveys maybe returned via e-mail to [email protected], fax at (202) 353-1079, or US mail – DEA, 600 Army Navy Drive, Room E-6377, Arlington, VA, 22202.

Electronic copies of the survey are available through DEA. Should you have any questions regarding this survey, or would like to obtain an electronic version, please contact Program Analyst, Mandy Healy, via e-mail [email protected] or phone (202) 307-7286.

Privacy Act Information

Authority: 21 U.S.C. 872(a)(5) and 873(a)(6)(B)

Purpose: Data received from these questionnaires will be used to compile a comprehensive document on the status of PMPs nationwide that will be available to interested parties when appropriate.

Routine Uses: Disclosures of information from this system are made to the following categories of users for the purposes stated.

1. Other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes

2. State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes.

3. State Prescription Monitoring Programs.

Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 hours per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Drug Enforcement Administration, FOI and Records Management Section, Washington, D.C. 20537; and to the Office of Management and Budget, Paperwork Reduction Project no. 1117-0037, Washington, D.C. 20503.

PRESCRIPTION MONITORING PROGRAM QUESTIONNAIRE

STATE: ______________________

POPULATION (http://factfinder.census.gov):_____________________

AGENCY NAME: _______________________________________________________

AGENCY CONTACT PERSON: Name: _____________________________________

Address: _______________________________________________________________

Telephone # ________________ Fax # _________________ E-Mail: _______________

AGENCY TYPE: Law Enforcement ____ Regulatory Board _____

Public Health _____ Other (Please specify) _____________

DOES YOUR STATE HAVE A STATE OPERATED PRESCRIPTION MONITORING PROGRAM? YES_______ NO_______

IF YES, HOW LONG HAS THE PROGRAM BEEN OPERATIONAL AND WHAT METHODS WERE UTILIZED TO PASS THE APPROPRIATE LEGISLATION THROUGH THE LEGISLATURE?_________________________________________________________

__________________________________________________________________________

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IF NO, IS YOUR STATE CONSIDERING CREATING OR IN THE PROCESS OF PROMULGATING REGULATIONS TO ESTABLISH A PRESCRITPION MONITORING PROGRAM?___________________________________________________________________

______________________________________________________________________________

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MONITORING PROGRAM: Electronic Data Transfer:______ State-issued forms: _____ Both: _____

Please specify type of form used: Single ____ Duplicate _____ Triplicate ______

Serialized (which schedules):________________

PRACTITIONER INFORMATION

Number of Practitioners (def 21 CFR 1300.01 (17)): ___________________

Separate State Controlled Substance Registration: Yes: _____ No: _____

If Yes, what is the fee? $__________________

Number of Pharmacies: ___________________

PROGRAM INFORMATION

Operating Budget (please attach an itemized budget, if available) $_________________

Program Staff includes the following (number of employees and their function): __________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Cost of state-issued prescription forms (if used): $ __________________

What is the program’s funding source? If funding comes from multiple sources, please specify percentage from each source. ____________________________________________________

____________________________________________________________________________

PROGRAM DATA

Number of prescriptions processed in FY 2004. ____________________

Cost for data processing per month (including collecting data, filing, data entry, analysis, and storage fees): $_______________________________________________________________

Number of Actions Taken Using PMP Information (including investigations initiated, requests from practitioners and/or pharmacists): ____________________________________________

Of the cases generated, how many cases were generated for the following reasons:

Forgery:____________

Theft:______________

Doctor Shopping:______________

Illegal Prescription Sales:_________________

DRUG DATA COLLECTED: Please indicate all that apply.

Federal Schedule II _____ Schedule III _____ Schedule IV _______ Schedule V _______

Please list additional drugs or classes of drugs: _______________________________________

_____________________________________________________________________________

Please list any exemptions/exceptions to reporting requirements:__________________________

_____________________________________________________________________________

DATA COLLECTION FORMATS.

If you are using the American Society of Automation in Pharmacy (ASAP) format, which version are you using? ASAP 95________; ASAP 97_________; ASAP 99____________

Pharmacies send data in the following formats (fill in the percentage of prescriptions sent in each format that applies – should total to 100%)

Electronic Transfer -- ______% Disk -- _______%

Tape -- ______% Universal Claim Forms -- _______%

Other -- ______% State-issued Prescription Forms -- _______%

If other, please describe: _____________________________________________________

_________________________________________________________________________

Do you anticipate any changes to the percentages provided above? If so, please explain:

___________________________________________________________________________

___________________________________________________________________________

CURRENT DATA COLLECTION METHOD. Pharmacies send prescription data to:

Our state agency _____ Our contractor, who is __________________________

Do you anticipate any changes to the collection method described? If so, please explain:

_________________________________________________________________________

How often are pharmacies required to submit data? _______________________________

________________________________________________________________________

CONFIDENTIALITY/ACCESS TO PMP DATA. The following individuals/entities are authorized to access data collected by PMP (Check all that apply) :

State Licensing Boards: ______ Prescribers for bona fide patients: ______

State/Local Law Enforcement: ______ Dispensers for bona fide patients: ______

DEA Investigators: ______ Researcher (If yes, are there any ______

restrictions?) _______________________

Other (specify): ____________________

PMP SUPPORT PROGRAMS. Please describe programs in place or anticipated that are designed to enhance the effectiveness of your prescription monitoring program, including:

Educational Programs: _______________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Treatment programs:___________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Other State Laws that Complement PMP (i.e., use of safety prescriptions, criminalization of doctor shopping, prohibition against self-prescribing). Please include statute citation. _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

INTERSTATE PRESCRIPTION TRANSACTIONS

Do mail-service and/or internet pharmacies operate within your state? Yes: _____ No: _____

Does your state require the registration/licensure of mail-order and/or

Internet pharmacies filling prescriptions for individuals in your state? Yes: _____ No: _____

Does your PMP have the capability of providing reports to other states?

regarding prescription activity of out-of-state prescribers or patients? Yes: _____ No: _____

If yes to above, are these reports routinely disseminated? Yes: _____ No: _____

If no to above, what obstacles exist that inhibit the dissemination of information to other states?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Program Highlights

Please describe any highlights of your program that occurred over the past two years._________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

STATUTES & REGULATONS – Please provide a website reference for state statutes and regulations regarding your prescription drug monitoring program.

_____________________________________________________________________________

_____________________________________________________________________________

WEBSITE – Please provide the website where program information on your state PMP can be located if applicable.

_____________________________________________________________________________

RESPONDENT FEEDBACK – In developing this questionnaire we attempted to be as thorough as possible without being overly burdensome. How did we do? Please provide your comments. ____________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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SUBMIT COMPLETED FORM TO: E-mail: [email protected]

Physical Address: Mandy Healy

Drug Enforcement Administration

600 Army Navy Dr. ODL

Arlington, VA 22202