Bicillin L-A Critical Shortage Survey

The National Coalition of STD Directors (NCSD) is closely monitoring the availability and supply of Bicillin L-A (penicillin G benzathine injectable suspension) amidst a critical shortage and pending stockout situation. We are interested in assessing the current stock at sexual health clinics and the impact of this shortage on your clinic operations. All responses are confidential and will be utilized in our advocacy. If you have any questions about the survey or need any additional information, please contact Cait Shea at cshea@ncsddc.org
1.Name
2.Email address of person completing survey
3.Clinic Name
4.Where is your clinic located (city and state or territory)?
5.Which of the following best describes your clinic? 
6.How many individuals, on average, do you serve each month? 
7.Approximately how many total patients present to your clinic for syphilis screening/testing/treatment on a daily basis?
8.How many times have you attempted to purchase Bicillin L-A in the last 3 months? 
9.In the past three months, have you ever attempted to place an order for Bicillin L-A that could not be filled, meaning you received none of the doses you ordered?
10.If you answered yes to the previous question, what percentage of your orders in the past three months were not filled?
11.In the past three months, have you ever placed an order for Bicillin L-A that was only partially filled, meaning you only got a portion of the doses you ordered?
12.If you answered yes to the previous question, what percentage of your orders in the past 3 months were only partially filled? 
13.Of the orders that were partially filled, what's the lowest percentage of a single order that's been filled?
14.At any point in the past three months, have you had a Bicillin L-A order delayed, meaning you did not receive it in the anticipated time frame?
15.Since the Bicillin L-A shortage, have you been prioritizing Bicillin L-A for pregnant patients?
16.Have you had to borrow Bicillin L-A from low-volume clinics/programs nearby?
17.Have you been diverting patients who require Bicillin L-A to other area clinics?
18.Have you been diverting patients who require Bicillin L-A to a local hospital/emergency room?
19.How has the shortage impacted your regular clinical operations? (Check all that apply)
20.How has the Bicillin L-A shortage practically impacted your clinic/program's ability to serve patients/clients?
21.What else should we know about how the Bicillin L-A shortage is impacting your clinic/program/community?
22.Besides more medication, what is your most pressing need at this time in order to cope with the Bicillin L-A shortage?