POPPP Membership Survey

Question Title

1. Please provide the following information.

Name:

Organization:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Country:

Email Address:

Phone Number:

Question Title

2. Degree

Ph.D.

Psy.D.

Ed.D.

D.S.W.

M.A./M.S.

Other (please specify)

Question Title

3. Title of Position:

Question Title

4. Memberships, Certification, Licensure

	Yes	No
APA Member?	APA Member? Yes	APA Member? No
State Psychological Association Member?	State Psychological Association Member? Yes	State Psychological Association Member? No
A.B.P.P.?	A.B.P.P.? Yes	A.B.P.P.? No
Licensed as a Psychologist?	Licensed as a Psychologist? Yes	Licensed as a Psychologist? No

Question Title

5. Employment Setting:

Private Hospital

Medical School

Teaching Hospital

Veterans Affairs Medical Center

Military Medical Center

State/County Hospital

University

School District/System

Community Mental Health Center

Social Service Agency

Independent Practice

Other

Question Title

6. Membership Terms

I wish to join Psychologists Opposed to Prescription Privileges for Psychologists (POPPP). I understand that whereas as an individual I am free to address this matter on my own in whatever ways I wish, I agree not to make any public statements on behalf of POPPP without the approval of the Board of Advisors. As a member of POPPP, I am pleased to further the purpose of the organization (e.g., contribute news about prescription privileges activities in my jurisdiction to POPPP; disseminate POPPP materials; provide advocacy on this matter provide advocacy on this matter opposing prescription privileges). There is no membership fee for this organization.

I agree to the above membership terms:

Yes

Question Title

7. Attestation

I oppose efforts for psychologists to obtain prescription privileges based on abbreviated training that does not meet or exceed the educational requirements of other prescribing professions, including the undergraduate prerequisites outlined in the APA ad hoc Task Force on Psychopharmacology (Smyer et al., 1993).

Yes

Question Title

8. Membership Level

Note:
1. Advocacy documents will not include contact information but will include affiliation and possibly jurisdiction.
2. I understand that I am voluntarily joining POPPP and may withdraw from it at anytime by contacting the organization.

Full Member: I consent to allow my name and affiliation to be listed in the POPPP membership list and on other advocacy documents, including petitions, to which the public will have access

Affiliate Member: Please withhold my name and affiliation on advocacy documents.

Student Member

Question Title

9. Are there any roles or projects associated with POPPP with which you would like to help?

Question Title

10. Comments

Welcome to POPPP. Thank you for joining. For more information about POPPP link to www.poppp.org

Question Title

1. Please provide the following information.

Question Title

2. Degree

Question Title

3. Title of Position:

Question Title

4. Memberships, Certification, Licensure

Question Title

5. Employment Setting:

Question Title

Question Title

Question Title

8. Membership LevelNote: 1. Advocacy documents will not include contact information but will include affiliation and possibly jurisdiction.2. I understand that I am voluntarily joining POPPP and may withdraw from it at anytime by contacting the organization.

Question Title

9. Are there any roles or projects associated with POPPP with which you would like to help?

Question Title

10. Comments

8. Membership Level

Note:
1. Advocacy documents will not include contact information but will include affiliation and possibly jurisdiction.
2. I understand that I am voluntarily joining POPPP and may withdraw from it at anytime by contacting the organization.