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Perinatal OUD ECHO Survey: Participant Application

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This program is designed to train Illinois healthcare professionals (physicians, nurse practitioners, physician assistants, nurse midwives, social workers, peer recovery coaches, medical assistants, doulas, etc.) in the assessment and treatment of opioid use disorders in their clinical settings for pregnant individuals. The training will provide not only clinical guidance but also provide technical support around the clinical workflows, policies, and protocols to ensure compliance with clinical standards and evidence-based practice. Each participant will receive a certificate and approximately 12 hours of continuing education credits upon full completion.

Program Co-Directors: TBD

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Last Name

* must provide value

First Name

* must provide value

Credentials

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MD/DO (Physicians)

DNP/ANP/FNP (Nurse Practitioners/APRNs)

PA (Physician Assistant)

Doula/Midwife

Nurse (RN)

Social Worker (LSW/LCSW)

Peer Support Specialist

Medical Assistant

Other

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If listed 'Other' describe credentials:

Email Address

* must provide value

Phone Number

* must provide value

Discipline or Specialty (Select your primary field)

* must provide value

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

Psychiatry or Mental Health Provider

Addiction or Substance Use Treatment Provider

Obstetrics/Gynecology (OB/GYN)

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Name of your PRIMARY practice location

* must provide value

Zipcode of your PRIMARY practice location

* must provide value

Which of the following best describes the PRIMARY setting where you are currently working?

* must provide value

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

Other

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If listed "Other", please describe:

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