Drug Shortage Survery

The availability of critical lifesaving medications has become a serious concern across the health care system, including ASCs.

Please help us take on this problem by completing the short 5 minute survey below.

For more information on drug shortages or ASC advocacy in general, please visit our webpage at www.ascassociation.org and select Drug Shortages from the Government Advocacy tab.

You should complete one survey for each drug in short supply.

Question Title

* 1. Which drug are you experiencing a shortage of?

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* 2. Please indicate the state in which your practice is located.

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* 3. Please select your type of Ambulatory Surgery Center.

Dermatology

Endoscopy

Gastroenterology

General Surgery

OB/GYN

Ophthalmology

Orthopedics

Pain Management

Plastic

Urology

Vascular

Other (please specify)

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* 4. If you have been experiencing a rise in price on drugs you've found to be in short supply, how much has the price gone up?

25% or less

50%

100%

200%

I have not noticed a price difference.

Other (please specify)

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* 5. Please indicate the frequency with which your practice is experiencing drug shortages.

Daily

Weekly

Monthly

Have not experienced shortages

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* 6. Please provide us with any addiction information or experiences you have encountered during the drug shortage that can be used during our advocacy efforts on this issue.

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* 7. Contact Information (Optional)

ASC Name:

Your Name:

Title/Position:

Address:

State:

City:

Zip:

Email Address:

Phone Number:

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