OUD ECHO Survey A: Fellowship Application

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Required format:

GVvUNuzyPmroNzZS3sXf3jMZyL947rfyFUiEg

This program is designed to train Illinois primary care providers (physicians, nurse practitioners, and physician assistants) in the assessment and treatment of opioid use disorders in their clinical settings. The training will provide not only clinical guidance but also technical support around the clinical workflows, policies, and protocols to ensure compliance with clinical standards and evidence-based practice. Upon full completion, each participant will receive a certificate and approximately 40 hours of continuing education credits.

Please fill out the application completely.

Deadline for application:

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Last Name

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First Name

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Credentials

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MD/DO (Physicians)

DNP/ANP/FNP (Nurse Practitioners/APRNs)

PA (Physician Assistant)

RN/LPN (Nurse)

LSW/LCSW (Social Worker)

CPRS/CRSS (Recovery Specialist)

Pharmacist

Other

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Other

Email Address

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Phone Number

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Discipline or Specialty (Select your primary field)

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Primary Care Provider (Internal Medicine, Family Medicine, General Practice)

Psychiatry or Mental Health Provider

Addiction or Substance Use Treatment Provider

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Which of the following practice settings best describes the MAIN setting where you are currently or will be prescribing buprenorphine?

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Community Health Center/FQHC/Rural Health Center

Emergency Department

Hospitalist/Inpatient Consult Team

Licensed Addiction Treatment Facility (licensed outpatient, residential, opioid treatment program)

Private Practice

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Name of your PRIMARY practice location

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Five-digit zip code of your PRIMARY practice location

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Do you treat patients who live in Illinois at your primary practice location?

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Yes

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This program is funded with money from the state of Illinois. Thus, participants must treat patients who are living in Illinois. You are thus not eligible to apply.

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