2023 Training for Cancer Health Care Professionals in Biopsychosocial Pain Management and Quality Improvement

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

Social Worker

Nurse Practitioner (NP)

Registered Nurse (RN)

Physician

Psychologist/Clinical Psychologist/Mental Health Counselor

Clinical Pharmacist/Recreational Therapist/Chaplain

Other (please specify)

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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

Cancer Center

Major Medical Center

VA Hospital

Community Cancer Setting

Other (please specify)

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* 8. City / State / Country

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* 9. Phone Number

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* 10. Gender

Female

Male

Transgender FtM

Transgender MtF

Neither exclusively male or female

Prefer not to answer

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* 11. Race (Based on US Census)

American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American – A person having origins in any of the Black racial groups of Africa.

Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

More than one Race

Unknown

Prefer Not to Answer

Other (please specify)

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* 12. Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Unknown

Prefer Not to Answer

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

% Asian/Pacific Islander

% African American

% White

% American Indian/Alaskan Native

% Hispanic/Latino

% Other/Unknown

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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.