PSI Collaborative Practice Interest Survey PSI Collaborative Practice Interest Survey Question Title * 1. What is your pharmacy practice setting? Grocery store Health-system inpatient Hospital outpatient Independent Large chain (more than 5) Small chain (5 or less) Question Title * 2. Consider the following Immunizations collaborative practice agreement (CPAs). Which are currently in use at your site/pharmacy? Which would you be interested in using in the future? Which would you be willing to purchase as a service provided to you? Check all that apply. Currently in Use Interested for Future Willing to Purchase Influenza Influenza Currently in Use Influenza Interested for Future Influenza Willing to Purchase Shingles Shingles Currently in Use Shingles Interested for Future Shingles Willing to Purchase Pneumonia Pneumonia Currently in Use Pneumonia Interested for Future Pneumonia Willing to Purchase Meningitis Meningitis Currently in Use Meningitis Interested for Future Meningitis Willing to Purchase Tetanus/diphtheria/pertussis Tetanus/diphtheria/pertussis Currently in Use Tetanus/diphtheria/pertussis Interested for Future Tetanus/diphtheria/pertussis Willing to Purchase Other (please specify) Question Title * 3. Consider the following Disease State Management collaborative practice agreements (CPAs). Which are currently in use at your site/pharmacy? Which would you be interested in using in the future? Which would you be willing to purchase as a service provided to you? Check all that apply. Currently in Use Interested for Future Willing to Purchase Hypertension Hypertension Currently in Use Hypertension Interested for Future Hypertension Willing to Purchase Diabetes Diabetes Currently in Use Diabetes Interested for Future Diabetes Willing to Purchase Asthma Asthma Currently in Use Asthma Interested for Future Asthma Willing to Purchase COPD COPD Currently in Use COPD Interested for Future COPD Willing to Purchase Pain Pain Currently in Use Pain Interested for Future Pain Willing to Purchase Other (please specify) Question Title * 4. Consider the following Public Health Concerns collaborative practice agreements (CPAs). Which are currently in use at your site/pharmacy? Which would you be interested in using in the future? Which would you be willing to purchase as a service provided to you? Check all that apply. Currently in Use Interested for Future Willing to Purchase Naloxone Naloxone Currently in Use Naloxone Interested for Future Naloxone Willing to Purchase Epi-pens Epi-pens Currently in Use Epi-pens Interested for Future Epi-pens Willing to Purchase Birth Control Birth Control Currently in Use Birth Control Interested for Future Birth Control Willing to Purchase Other (please specify) Question Title * 5. How do you obtain collaborative practice agreements (CPAs) at your practice site? Work with local physician partner(s) Work with local physician partner(s) Work in a clinic/ambulatory care setting Work in a clinic/ambulatory care setting Purchase desired CPAs from wholesaler Purchase desired CPAs from wholesaler Receive CPAs from corporate office Receive CPAs from corporate office My site/pharmacy has been unable to obtain physician partner(s) for desired CPAs My site/pharmacy has been unable to obtain physician partner(s) for desired CPAs I am not interested in utilizing CPAs in my pharmacy/site I am not interested in utilizing CPAs in my pharmacy/site Question Title * 6. Would you be interested in participating in a pilot project to assist patients in the management of hypertension? Yes (Please provide your contact information below) No Question Title * 7. Would you be interested in hearing more about collaborative practice agreement opportunities from PSI? Yes (Please provide your contact information below) No Question Title * 8. Contact Information (Optional) Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Done