Attachment 1. Feedback Moderator Guide
OMB Control No. 0920-1050
Exp. Date 05/31/2022
Public reporting burden of this collection of information is estimated to average 30 minutes per respondent. 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia, 30333; ATTN: PRA (0920-1050).
Date of interviews: Click or tap to enter a date.
State: Click or tap here to enter text.
Individuals participating in the call: Click or tap here to enter text.
Can the state legally identify patients after the action? (If no, skip to question 2)
Can the state review medical charts of affected patients?
Can the state use PDMP data to identify patients?
Can the state legally reach out and contact affected patients?
Which patients need to be contacted?
Click or tap here to enter text.
Additional notes on state statutory requirements related to patient records, if applicable
Click or tap here to enter text.
What are some communications strategies the health department plans to utilize?
☐ Flyers for affected patients
☐ Communications to ERs, other docs, pharmacies
☐ Letter for providers who take on new patients
☐ Hotline for affected patients and OUD information
☐ Other: Click or tap here to enter text.
☐ Information unavailable
Additional notes on communications plan, if applicable:
Click or tap here to enter text.
What on-site support during action can the state provide?
☐ Referral specialist
☐ Mobile unit
☐ Counselors
☐ Naloxone training
☐ Case managers
☐ State cannot provide on-site support
☐ Other: Click or tap here to enter text.
☐ Information unavailable
Can the state legally refer affected patients to another provider?
Can the state utilize insurance providers and their case managers to link patients to care?
What types of providers are available for patient referrals?
☐ MAT providers
☐ Pain management providers
☐ No known providers
☐ Other: Click or tap here to enter text.
☐ Information unavailable
Additional notes on linkage to care plan, if applicable:
Click or tap here to enter text.
What is the Overdose Education and Naloxone Distribution (OEND) Plan?
Click or tap here to enter text.
What types of provider support are available?
☐ General MAT prescribing
☐ Pain treatment for complex patients
☐ Safe, patient-centered opioid tapering guidance?
☐ Other: Click or tap here to enter text.
☐ No support available
☐ Information unavailable
What is the format of provider support?
☐ In-person mentoring
☐ In-person didactic training
☐ Online mentoring
☐ Online training
☐ Telehealth consultation
☐ Other: Click or tap here to enter text.
☐ No support available
☐ Information unavailable
Additional notes on training, if applicable:
Click or tap here to enter text.
Notes on trusted contacts’ next steps
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Contact information for parties on the call
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Fogarty, Hannah (CDC/DDNID/NCIPC/DOP) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |