11 Eligibility Screening

Attachment 3: ELIGIBILITY SCREENING INSTRUMENT

Web-based Skills Training for SBIRT (Screening Brief Intervention and Referral to Treatment)

OMB # 0925-XXX

Expiration Date xx/xxxx

Public reporting burden for this collection of information is estimated to average less than 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. Each time the assessment is completed, it is expected to be completed in a single sitting. 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-xxxx*).  Do not return the completed form to this address.

Eligibility Screening (conducted online)

Please answer the following questions to help us determine if this study is a good fit for you. You do not have to answer any questions that you do not want to, however if you choose not to answer these questions you will not be able to participate in this study.

1. What is your area of medical practice?

   • family practice

   • general practice

   • internal medicine

   • obstetrics/gynecology

   • other
     
     
     
     

2. What percentage of your work time is spent providing clinical services?

   • 10%

   • 20%

   • 30%

   • 40%

   • 50%

   • 60%

   • 70%

   • 80%

   • 90%

   • 100%
     
     
     
     

3. In what state do you practice?

   • (Users will select their answer from a drop down list of the 50 U.S. states)
     
     
     
     

4. During the past two years, have you participated in training activities that addressed substance use screening and/or treatment of tobacco, alcohol, or other drugs?

   • Yes

   • No

Closing statement for ineligible subjects—ineligible subjects will be sent to a page with the following statement.

Thank you for your interest in this study, but based on the information you provided the study is not a good fit for you. The information you entered will be deleted from our database.