AHA/HVPAA Opioid Stewardship Collaborative Survey

1.Organization Name(Required.)

2.Team Lead Contact Information(Required.)

Name

Title

Address 1

Address 2

City

State

Zip Code

Phone

Assistant Name

Assistant Email

Assistant Phone

3.Please list 2-3 potential team members here. Teams should consist of at least three professionals (including the Team Lead) who will actively participate in phone conferences with mentors and the collaborative. For additional guidelines for your teams, please refer to the Team Guidelines.(Required.)

Team Member 1

Team Member 2

Team Member 3

4.Choose one topic for your project focus.(Required.)

Appropriate prescribing

Opioid recovery and medications for opioid use disorder

Alternative medications for pain management

5.Describe how participating in the Opioid Stewardship Program will address your needs.(Required.)

6.For teams comprised of medical students, please include the name and email of your faculty sponsor.

Faculty Sponsor

The Opioid stewardship collaborative includes monthly virtual interactions as follows:

1. 1 hour call with your cohort and mentor every other month beginning in January 2020 – Scheduled for the 2nd Wednesday of the month at 4 pm ET (1/8, 3/11, 5/13, 7/8, 9/9)

2. Educational webinars, in alternate months (12/11, 2/12, 4/8, 6/10, 8/12), the first of which will be held on Wednesday, December 11, 2019, at 4 pm Eastern on patient and family education and engagement

AHA/HVPAA Opioid Stewardship Collaborative

Apply for the AHA/HVPAA Opioid Stewardship Collaborative