BTI Training Registration Form Survey

With the help of a clinician, the odds of quitting tobacco more than double. While counseling and medication individually are effective for tobacco cessation, a combination of both is more effective. This training will show healthcare providers how to work with tobacco users to develop quit plans, to prescribe cessation medication and to refer them for lung cancer screenings.

Question Title

* 1. Contact Information

Name *

Organization *

Address *

Address 2

City/Town *

State *

ZIP Code *

Credentials

Email Address *

Phone Number *

Question Title

* 2. Organization Type (Please provide the type of Organization.)

Arkansas Federally Qualified Health Centers (FQHC)

Private Clinic

Community Based Clinic

Hospital

Community Organization

Behavioral Health Provider/Facility

Question Title

* 3. Have you previously attended a BTI Training hosted by ACC? If yes, please specify which training session/month you attended and what session(s) you completed.

February 2022

Billing and Coding

Motivational Interviewing

Pharmacotherapy

November 2021

Low Dose CT Screening

I have not previously attended BTI Training

Question Title

* 4. Which sessions do you plan to attend?

November 7 - Pharmacotherapy

November 8 - Motivational Interviewing

November 9 - Low Dose CT Screening & Billing and Coding

Question Title

* 5. BTI is a targeted training system for staff of Arkansas Federally Qualified Healthcare Centers. Are you currently employed with an Arkansas FQHC that provides tobacco cessation counseling?

Yes

Name of FQHC and Location

Question Title

* 6. Are you registering as an individual or a group?

Individual

Group

Question Title

* 7. (Group registration only). Please list Name, Credentials, and Email Address on separate lines for each participant in order for us to contact you.

Question Title

* 8. Please complete this quick survey to help ACC design programs to help healthcare providers better assist patients who use tobacco.

Does/would your clinic or healthcare system:

	Yes	No
Ask patients about their tobacco/nicotine use at every visit?	Ask patients about their tobacco/nicotine use at every visit? Yes	Ask patients about their tobacco/nicotine use at every visit? No
Refer patients to Be Well Arkansas for tobacco cessation counseling?	Refer patients to Be Well Arkansas for tobacco cessation counseling? Yes	Refer patients to Be Well Arkansas for tobacco cessation counseling? No
Provide patients with tobacco cessation counseling?	Provide patients with tobacco cessation counseling? Yes	Provide patients with tobacco cessation counseling? No
Bill Medicare or Medicaid for tobacco cessation counseling?	Bill Medicare or Medicaid for tobacco cessation counseling? Yes	Bill Medicare or Medicaid for tobacco cessation counseling? No
Have a prompt in the electronic medical record (EMR) to ask patients about their tobacco/nicotine use?	Have a prompt in the electronic medical record (EMR) to ask patients about their tobacco/nicotine use? Yes	Have a prompt in the electronic medical record (EMR) to ask patients about their tobacco/nicotine use? No
Be interested in training on how to bill/code for tobacco cessation counseling through Medicare and Medicaid?	Be interested in training on how to bill/code for tobacco cessation counseling through Medicare and Medicaid? Yes	Be interested in training on how to bill/code for tobacco cessation counseling through Medicare and Medicaid? No
Be interested in additional training for tobacco cessation interventions such as tobacco treatment specialist (TTS) training?	Be interested in additional training for tobacco cessation interventions such as tobacco treatment specialist (TTS) training? Yes	Be interested in additional training for tobacco cessation interventions such as tobacco treatment specialist (TTS) training? No
Be interested in receiving information/training as needed to implement systems change to integrate tobacco cessation interventions as a core component of patient treatment?	Be interested in receiving information/training as needed to implement systems change to integrate tobacco cessation interventions as a core component of patient treatment? Yes	Be interested in receiving information/training as needed to implement systems change to integrate tobacco cessation interventions as a core component of patient treatment? No
Be interested in receiving free Continuing Education Credits?	Be interested in receiving free Continuing Education Credits? Yes	Be interested in receiving free Continuing Education Credits? No

Question Title

* 9. How did you hear about the BTI Training?

Arkansas Cancer Coalition Electronic Newsletter

Email Notice

Arkansas State Board of Nursing Publication or Online Edition

Networking

Arkansas Academy of Family Physicians Magazine

Other (please specify)

BTI Training Registration Form

Question Title

* 1. Contact Information

Question Title

* 2. Organization Type (Please provide the type of Organization.)

Question Title

* 3. Have you previously attended a BTI Training hosted by ACC? If yes, please specify which training session/month you attended and what session(s) you completed.

Question Title

* 4. Which sessions do you plan to attend?

Question Title

* 5. BTI is a targeted training system for staff of Arkansas Federally Qualified Healthcare Centers. Are you currently employed with an Arkansas FQHC that provides tobacco cessation counseling?

Question Title

* 6. Are you registering as an individual or a group?

Question Title

* 7. (Group registration only). Please list Name, Credentials, and Email Address on separate lines for each participant in order for us to contact you.

Question Title

* 8. Please complete this quick survey to help ACC design programs to help healthcare providers better assist patients who use tobacco. Does/would your clinic or healthcare system:

Question Title

* 9. How did you hear about the BTI Training?

* 8. Please complete this quick survey to help ACC design programs to help healthcare providers better assist patients who use tobacco.

Does/would your clinic or healthcare system: