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AMNet Survey

AMNET Survey

1. How did you hear about AMNet? *This question is required.

Please enter an 'other' value for this selection.

2. Which of the following memberships are you holding? (Check all that apply)

3. Which best describes the location of your practice?

4. Which best describes your practice?

Please enter an 'other' value for this selection.

5. Which of the following types of clinicians are in your practice? (select all that apply)

6. Approximately how many total patients does your practice have? (i.e. accounting for all clinicians in the practice)

7. How many unique patients does your practice see in a typical week? (write number in numeric form) This question requires a valid number format.

8. Approximately what percentage of your practice's patients are being treated for opioid use disorder?

9. How many of your patients have opioid use disorder (OUD)? *This question is required. This question requires a valid number format.

10. How many of your patients have alcohol use disorder (AUD)? *This question is required. This question requires a valid number format.

11. How many of your patients have both OUD and AUD? *This question is required. This question requires a valid number format.

12. Does your practice administer a standardized screening tool to all patients for the misuse of:

	Alcohol
	Tobacco
	Illicit drug
	Prescription medication

13. Does your practice prescribe buprenorphine?

14. Does your practice provide extended-release naltrexone for opioid use disorder?

15. Does your practice provide extended-release naltrexone for alcohol use disorder?

16. Does your practice have an electronic health record?

17. Is your practice affiliated with an academic institution?

Please describe the affiliation. (no more than 100 words).

18. Is your practice covered by the Alcohol and Drug Confidentiality Regulations (42 CFR Part 2)?

19. Would providers in your practice be interested in participating in clinical research studies? (Response to this question will be used for planning purposes)

20.

Would you like to be part of this initiative or receive more information about AMNet?

Contact Information *This question is required.

First Name

Last Name

Email Address

Practice Name

If selected to join AMNet, would you be willing to complete approximately 2 hours of optional online training about research and opioid use disorder treatment?

21. Would you be willing to answer a few questions about how your practice is impacted by COVID-19?