CPS Pharmacy Collaborative Practice Agreement Utilization - Baseline Survey

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* 1. Information

Name

Company / Organization

Email Address

Phone Number

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* 2. Practice / Billing Setting (Choose all that apply)

Community Pharmacy (Independent)

Community Pharmacy (Chain / Grocery Store / Big box)

Hospital / Health System Outpatient Clinic

Non-Hospital / Health System Outpatient Clinic

Federally Qualified Health Center

Other (please specify)

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* 3. Do you / your organization currently practice under pharmacist collaborative practice agreements (CPAs), also known as Collaborative Drug Therapy Management Protocols (CDTM)?

Yes

No

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* 4. If you / your organization utilize CPAs or CDTMs in your practice, please list CPAs / CDTMs currently in use:

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* 5. Do you / your organization currently utilize statewide protocols (SWPs) in your practice?

Yes

No

Other (please specify)

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* 6. If you / your organization utilize SWPs in your organization, please check the SWPs that you/your organization utilizes (Choose all that apply):

HIV PrEP/PEP

Hormonal Contraception

Smoking Cessation

Statin Therapy

None of the above

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* 7. If you / your organization utilize CPAs, CDTMs or SWPs, are you receiving reimbursement for those services under the pharmacist provider laws?

No

Yes

If yes, please explain what services you are receiving reimbursement for (CPA, CDTM, SWP, others)