Injury Plus SEEK - W2 Pre-work Survey

Expect this survey to take approximately 15 minutes to complete. The information you provide will be used to improve future waves of the Injury Plus SEEK project and Ohio AAP programs. You may denote "N/A" if you do not have an answer for any question, and use estimates or your best knowledge if needed.

An * indicates a required field.

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* 1. Please select your practice from the drop down menu:

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* 2. Please provide your name:

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* 3. Which of the following best describes your role (choose ONE):

Physician Lead or Core QI Team LEAD (will complete information about the practice on the next screen)

Participating Physician

Physician Assistant

Nurse Practitioner

Other Clinical Staff

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* 4. Are you seeking Maintenance of Certification credit for your participation?

Yes

If yes, through what organization: