Form 2 Screening Instrument

Attachment 3: Screening Instrument

Web Based Training for Pain Management Providers (NIDA)

April 12, 2010

1. SCREENING INSTRUMENT

OMB # 0925-XXX

Expiration Date xx/xxxx

BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This survey will be taken one time, at the beginning of the study. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0486). Do not return the completed form to this address.

Screening Survey for Physicians

Clinical Tools developed a new web-based educational and clinical skills training experience funded by the National Institute on Drug Abuse (NIDA). The website is for health care providers on preventing drug misuse and addiction in chronic pain patients. If you qualify to participate, we will invite you to take the training program and complete several assessments afterwards.

Please complete the form below so that we can determine your eligibility for the study. If you meet study eligibility, we will contact you via email with further information on the study.

Eligibility

1. I am a physician who treats patients with pain in any capacity.

Yes

No

(If they answer “No”, they are not eligible and will be taken to page #3, “Not Eligible for this Study”)

2. I have a specialty certification or the equivalent in:

Neither

Pain Medicine

Addiction Medicine

Both Pain and Addiction Medicine

(If they answer “Pain Medicine”, “Addiction Medicine”, or “Both Pain and Addiction Medicine”, they are not eligible and will be taken to page #3, “Not Eligible for this Study”)

3. I am a US resident.

Yes

No

(If they answer “No”, they are not eligible and will be taken to page #3, “Not Eligible for this Study”)

*The pain and addiction project is funded by NIDA contract #N43DA82213. This project has been reviewed and approved as exempt by the Clinical Tools, Inc. Institutional Review Board.*

Interview Sign-up

Please complete the form below to sign up for the interview.

1. Please enter your name and email address.

Name:

Email Address:

Phone Number:

2. What is your specialty?

Family Practice

Internal Medicine

OB/GYN

Emergency Medicine

Other (please specify)

Not Eligible for this Study

Pain or Addiction Specialists:
This survey is for primary care physicians and nurse practitioners without specialty certification or the equivalent in pain or addiction.

Non-US Residents:
If you do not reside in the United States, we regret that you cannot participate due to funding restrictions.

Recent Participant:
Due to funding restrictions, you may participate in only one survey per project.

What's Next? (only eligible participants are sent to this page)

You qualify for participation in this research. You will be sent an email shortly with further information.

Screening Survey for Nurse Practitioners

Clinical Tools developed a new web-based educational and clinical skills training experience funded by the National Institute on Drug Abuse (NIDA). The website is for health care providers on preventing drug misuse and addiction in chronic pain patients. If you qualify to participate, we will invite you to take the training program and complete several assessments afterwards.

Please complete the form below so that we can determine your eligibility for the study. If you meet study eligibility, we will contact you via email with further information on the study.

Please complete the form below so that we can determine your eligibility for the interview:

Eligibility

1. I am nurse practitioner who treats pain patients.

Yes

No

(If they answer “No”, they are not eligible and will be taken to page #3, “Not Eligible for this Study”)

2. I have specialty certification or the equivalent in:

Pain Medicine

Addiction Medicine

Both

Neither

(If they answer “Pain Medicine”, “Addiction Medicine”, or “Both”, they are not eligible and will be taken to page #3, “Not Eligible for this Study”)

3. I am a US resident.

Yes

No

(If they answer “No”, they are not eligible and will be taken to page #3, “Not Eligible for this Study”)

Note: Development of Web Based Training in Addiction Medicine for Pain Management Providers is funded by a contract with the National Institute on Drug Abuse NIDA Contract No. HHSN271200900003C. This research was reviewed by the Clinical Tools IRB (FWA00002873) and determined to be exempt from IRB oversight. Clinical Tools, Inc. is a physician-owned, multimedia company headquartered in Chapel Hill, North Carolina. Clinical Tools combines expertise in healthcare content and computer application development to provide Internet-based education and information for professionals and consumers.

Interview Sign-up

1. Please enter your name, email address, and phone number.

Name:

Email Address:

Phone :

2. What is your specialty?

Family Medicine

Internal Medicine

OB/GYN

Emergency Medicine

Other (Please specify):

Not Eligible for this Study

Pain or Addiction Specialists:
This survey is for nurse practitioners without specialty certification or the equivalent in pain or addiction.

Non-US Residents:
If you do not reside in the United States, we regret that you cannot participate due to funding restrictions.

What's Next? (only eligible participants are sent to this page)

You qualify for participation in this research. You will be sent an email shortly with further information.

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