Pediatrician Focus Group & Interviews: Screening Survey
Thank you for your interest in participating in a focus group on June 25th from 12 - 1:30 p.m. ET, or in an interview on June 26th between the hours of 12 - 3 p.m. ET.

Please complete the following form so we can get to know you better.

If you have any questions, please contact Jana Scoville at /404-388-4200.

We will notify you as soon as possible to confirm participation.

Email address *
What is your name? *
Your answer
What kind of medical provider are you? *
How long have you been practicing medicine? *
What is your age range? *
On average how many patients do you see a week? *
What kind of setting do you work in? *
Where is your practice or clinic? *
What state or territory do you work in? *
Your answer
Have you ever provided care for infants or children who were exposed to opioids while their mothers were pregnant? Note: “opioids” to refer to opioid prescription medications, recreational or non-prescribed opioids and opioid agonist medications (e.g.: OxyContin, Percocet, Vicodin, heroin, Fentanyl, methadone, etc.). *
[If yes to #10] Approximately how many patients with a history of opioid use have you cared for? (Note: an estimate is ok) *
Have you ever prescribed or referred a patient for treatment or care related to opioid exposure? *
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