PA OPIOID OVERDOSE REDUCTION
Stigma Reduction Initiative

Baseline Survey of Medical Professionals and Practice Behavior Assessment

DEMOGRAPHICS

Question Title

1. Please indicate the date of survey:

Date / Time

Date

Question Title

2. Please indicate your age:

Under 18

18-24

25-34

35-44

45-54

55-64

65-74

75+

Question Title

3. Please indicate your gender:

Male

Female

Non-binary/third gender

Prefer to self-describe

Prefer not to answer

Question Title

4. Please indicate your race:

American Indian or Alaskan Native

Asian/Pacific Islander

Black/African American

Hispanic

White/Caucasian

Other (please specify)

Question Title

5. Please indicate your healthcare discipline:

Physician

Physician Assistant

Nurse Practitioner

Nurse

Pharmacist

Other (please specify)

Question Title

6. Please indicate where you practice (select more than one if applicable):

Primary Care

Emergency Medicine

Inpatient Hospital

Hospital Pharmacy

Community Pharmacy

Other (please specify)

Question Title

7. Please describe the majority of your shifts (select more than one if applicable):

Daytime Weekdays

Daytime Weekends

Nighttime Weekdays

Nighttime Weekends

Question Title

8. Please indicate the best description of the area in which you serve:

Urban

Suburban

Rural

Mixed

PA OPIOID OVERDOSE REDUCTION
Stigma Reduction Initiative

Baseline Survey of Medical Professionals and Practice Behavior Assessment

Question Title

1. Please indicate the date of survey:

Question Title

2. Please indicate your age:

Question Title

3. Please indicate your gender:

Question Title

4. Please indicate your race:

Question Title

5. Please indicate your healthcare discipline:

Question Title

6. Please indicate where you practice (select more than one if applicable):

Question Title

7. Please describe the majority of your shifts (select more than one if applicable):

Question Title

8. Please indicate the best description of the area in which you serve:

Question Title

9. Please indicate your length of time serving as a healthcare professional:

Question Title

10. Please indicate your zip code of residence:

Question Title

* 1. Please indicate the date of survey:

Question Title

* 2. Please indicate your age:

Question Title

* 3. Please indicate your gender:

Question Title

* 4. Please indicate your race:

Question Title

* 5. Please indicate your healthcare discipline:

Question Title

* 6. Please indicate where you practice (select more than one if applicable):

Question Title

* 7. Please describe the majority of your shifts (select more than one if applicable):

Question Title

* 8. Please indicate the best description of the area in which you serve:

Question Title

* 9. Please indicate your length of time serving as a healthcare professional:

Question Title

* 10. Please indicate your zip code of residence:

1. Please indicate the date of survey:

2. Please indicate your age:

3. Please indicate your gender:

4. Please indicate your race:

5. Please indicate your healthcare discipline:

6. Please indicate where you practice (select more than one if applicable):

7. Please describe the majority of your shifts (select more than one if applicable):

8. Please indicate the best description of the area in which you serve:

9. Please indicate your length of time serving as a healthcare professional:

10. Please indicate your zip code of residence: