The following 18 questions is requested for grant reporting purposes*

An application is required for each individual participating 

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Current Title/Position, Please select the best fitting for you

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* 5. Credentials (MD, PhD, NP, etc)

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* 6. Institution / Organization (Full Organization Name)

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* 7. Type of Institution

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* 8. City / State / Country

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* 9. Phone Number

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* 10. Gender

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* 11. Race (Based on US Census)

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* 12. Ethnicity

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* 13. Ethnicity of your clinic's or institution's cancer patient population (to total 100%)

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* 14. Describe your interest in improving psychosocial approaches to pain management in your clinical practice and setting (100-250 words recommended).

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* 15. Please describe in your opinion what would be needed to achieve 'good' implementation of these approaches in your setting? (100-250 words recommended).

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* 16. Please provide up to two paragraphs about (1) data on pain management and use of psychosocial services in your setting, and (2) what support you have in your setting to implement these approaches.

 
50% of survey complete.

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