By June 24, please work with your team to complete the following baseline surveys for the first quarter of 2019 (January-March).

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* 1. What is your health system name?

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* 2. Which site/hospital within your health system are you submitting data for?

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* 3. What is your name?

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* 4. Does your site currently have a process in place to provide ongoing OUD sensitivity training requirements for staff and providers?

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* 5. If you entered yes for question 4, which staff receive education? (Check all that apply)

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* 6. If you entered yes for question 4, please describe the education:

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* 7. If you entered yes for question 4, is staff education on substance use in pregnancy mandatory or volunteer?

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* 8. Does your site have standardized materials for educating women with OUD, regarding OUD and in pregnancy and mother’s role in NAS newborn care (i.e. pediatric consult, patient education materials)?

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* 9. If you entered yes for question 8, what patient education material is your health system providing to patients?

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* 10. Does your site use a validated, self-report screening tool for substance use in pregnancy?

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* 11. If you entered yes for question 10, which self-report screening tool is your health system using to screen pregnant women for OUD? (You may choose more than one answer. If your health system does not screen pregnant women for OUD, choose "none.")

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* 12. If you entered yes for question 10, which patients receive self-reported screening?

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* 13. If you entered yes for question 10, when do patients receive self-reported screening? (Check all that apply)

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* 14. Does your site use urine toxicology to identify substance use during pregnancy?

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* 15. If you entered yes for question 14, how would you describe your urine toxicology screening process?

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* 16. If you entered yes for question 14, when do patients receive urine toxicology screening? (Check all that apply)

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* 17. Does your site provide opioid pharmacotherapy for pregnant women with OUD?

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* 18. If you entered yes for question 17, which pharmacotherapy services does your site provide? (Check all that apply)

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* 19. Has your site developed referral relationships with any OUD treatment programs in your area/county?

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* 20. Does your site provide behavioral health services for pregnant women with OUD?

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* 21. If you entered yes for question 20, which services? (Check all that apply)

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* 22. If you entered yes for question 20, who provides the services? (Check all that apply)

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* 23. Has your site developed unique clinical pathways/order sets for pregnant women with OUD?

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* 24. If you entered yes for question 23, which pathways (Check all that apply)?

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* 25. If you entered yes for question 23, do clinical pathways include screening all pregnant women with OUD for additional co-morbidities?

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* 26. If you entered yes for question 25, which comorbidities?

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* 27. Is a “Plan of Safe Care” developed for all pregnant women with OUD prior to hospital discharge?

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* 28. If you entered yes for question 27, which care team develops this plan? (Check all that apply)

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* 29. Does your site provide immediate postpartum contraceptive counselling and services?

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* 30. If you entered yes for question 29, which contraceptive methods are provided in the immediate postpartum period? (Check all that apply)

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