2018_HS: Substance Use Disorder in Health Care Professionals

1. Please answer the following questions about you:

Please let us know a little bit about you. Starred items are required.

*First and Last Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

*Email Address:
(use work email if from a TCHP Organization)

Phone

Please indicate which organization you work for:

Please indicate your unit or work area. If you are not currently working, enter "not working."

Please select the situation listed below that best describes you.

I am a nurse and do not have a special certification.

I am a nurse with a special certification such as a CCRN, PCCN, etc.

I am not a nurse.

If you are not a nurse, please specify your profession.

I verify that I have read this home study.

Yes

No (not eligible for contact hours)