Attachment 3: Screening Instrument
Web Based Training for Pain Management Providers (NIDA)
April 12, 2010
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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | rossie |
File Modified | 0000-00-00 |
File Created | 2021-02-01 |