New York State Survey of Buprenorphine Providers

Thank you for taking the time to participate in this survey. Please note: none of the information you provide will be shared on a public directory. If you have any questions about this survey, please feel free to contact Dani Lloyd at Danielle.Lloyd@health.ny.gov or 518-474-7848

All questions are required, which means you cannot move on to the next question until you have provided a response. You can return to this survey and change your answers at any point until you click 'Done' at the end of the survey. Once you click 'Done' your survey will be submitted and you cannot make any additional changes.

Question Title

* 1. Please provide us with your contact information.

Name:

Zip Code:

County

Email Address:

Phone Number (Please indicate if office or personal):

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* 2. Please list any board certifications.

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* 3. Do you have a DATA waiver/X-DEA registration number to prescribe buprenorphine?

Yes