Form OMB No. 0917-0036- OMB No. 0917-0036- OMB No. 0917-0036-35, Providers - eRX Deployment

Providers - e-RX Deployment
1. 

REQUIRED OMB INFORMATION: 
Indian Health Service (IHS) Post Class Survey 

Form Approved 
OMB Form No. 0917­0036­35 
Expiration Date: 5/31/2015 

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information 
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917­0036. 
The time required to complete this information collection is estimated to average 5 minutes per response, including the 
time to review instructions, search existing data resources, gather the data needed, and complete and review the 
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for 
improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence 
Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer. 

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Providers - e-RX Deployment
2. Personal Information

1. Name:

2. Location:

3. Select the term(s) that best describes your role:
c Provider
d
e
f
g

c Facility CAC
d
e
f
g
c Pharmacist
d
e
f
g

c Clerk
d
e
f
g

c Other (please describe)
d
e
f
g

4. By the end of this training do you feel comfortable e­prescribing a new medication by
utilizing a medication quick order?

j Yes
k
l
m
n
j No
k
l
m
n

5. If No, Why?
5
6  

6. By the end of this training do you feel comfortable e­prescribing a complex medication
order (i.e. prednisone taper or warfarin dosing)?

j Yes
k
l
m
n
j No
k
l
m
n

7. If No, Why?
5
6  

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Providers - e-RX Deployment
8. By the end of this training do you feel comfortable printing a hard copy prescription for
medications that cannot be e­prescribed (i.e. controlled substances)?

j Yes
k
l
m
n
j No
k
l
m
n

9. If No, Why?
5
6  

10. By the end of this training do you feel comfortable verifying that a prescription was
successfully e­prescribed?

j Yes
k
l
m
n
j No
k
l
m
n

11. If No, Why?
5
6  

12. Do you understand that Demo patients are not permitted on the production system and
once you are live you will only be able to send prescriptions to live pharmacies?

j Yes
k
l
m
n
j No
k
l
m
n

13. If No, Why?
5
6  

14. Do you understand that only providers authorized to write prescriptions can access
the system?

j Yes
k
l
m
n
j No
k
l
m
n

15. If No, Why?
5
6  

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Providers - e-RX Deployment
16. Do you understand that if you fail to comply with the rules and regulations your access
to the e­Prescribing network will revoked?

j Yes
k
l
m
n
j No
k
l
m
n

17. If No, Why?
5
6  

18. Do you understand that if users who do not have prescription authority are given
access to the network that your entire site can be disconnected from the network?

j Yes
k
l
m
n
j No
k
l
m
n

19. If No, Why?
5
6  

20. What did you expect from the e­Prescribing Provider Training?
5
6  

21. Overall, do you feel that your objectives were met?

j Yes
k
l
m
n
j No
k
l
m
n

22. If No, please explain what could have been done better to meet those objectives.
5
6  

23. Looking back, how would you rate your knowledge of the E­Rx before the training?
j Poor
k
l
m
n
j Fair
k
l
m
n

j Good
k
l
m
n

j Very Good
k
l
m
n
j Excellent
k
l
m
n

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Providers - e-RX Deployment
24. Now that you have attended the training, how do you rate your knowledge of the
subject?
j Poor
k
l
m
n
j Fair
k
l
m
n

j Good
k
l
m
n

j Very Good
k
l
m
n
j Excellent
k
l
m
n

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