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Degree (As you want it to appear on your certificate) Required Degree is required

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Professional information

What is your profession? Required Profession is required

Specify, "Other" Required You must specify "Other"

Are you board certified by the American Board of Internal Medicine (ABIM)? Required Your ABIM answer is required

The SCOPE of Pain core curriculum and the New York-specific module are approved for ABIM Credit. The information gathered below (birth month/day, ABIM number, and your completion data) will be reported to the ACCME on your behalf

Month of birth Required Month of birth is required

Date of birth Required Date of birth is required

ABIM number (Don't know your number? Find it here) Required A valid ABIM number (6-digit integer) is required

Are you affiliated with any of these organizations? Required Organizational affiliation is required. If no affiliation, select "None"

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Practice information

Boston University requests the following prescribing practice information in order to ensure we are providing appropriate education for our audience. Thank you for completing the following information.

Indicate if you are able (licensed) to prescribe controlled substances (CS) Required Required

If "Yes," what type of registration allows you to do so? Required Required

Do you prescribe opioids for the management of chronic pain? Required Required

Do you perform the following when prescribing opioid analgesics for chronic pain?

Implement a Patient-Prescriber Agreement ("opioid contract") Required Educate my patient about proper opioid storage (e.g., locked box) Required Educate my patient about proper opioid disposal (e.g., DEA drug take-back programs and disposal locations) Required Educate my patients about risks of opioid overdose Required Co-prescribe naloxone with opioid analgesic prescriptions Required Monitor my patients with urine drug tests Required Monitor my patients with pill counts Required Monitor my patients with a Prescription Drug Monitoring Program Required

Are you DEA waivered ("X" number) to prescribe buprenorphine for patients with an opioid use disorder? Required Required

Which best describes your practice area? Required Speciality is required

Specify, "Other" Required You must specify "Other"

Do you perform surgical procedures? Required Required

Practice profile

How many years have you been in clinical practice? Required An answer is required

In what country is your primary practice? Required Required

In what state is your primary practice? Required Required

Please select item that best describes your practice setting Required Required

Specify, "Other" Required You must specify "Other"

Please select the item that best describes your practice location type Required Required

Which best describes your primary practice? Required Required

Misc

What was your reason for participating in SCOPE of Pain? (Check all that apply) Required

State mandated (licensing purposes)
Mandatory in workplace (internal policy)
Mandatory in profession (association policy/regulatory or accreditation purposes)
Informally mandatory (workplace or association strongly suggested/encouraged participation)
Not mandatory – Voluntarily participated due to personal interest/professional improvement/other
Do not know/not sureAt least one answer is required

Do you want to opt out of the Chobanian & Avedisian School of Medicine CCE Mailing List? Required Required

Prove you're not a robot: What is three plus seventeen? Required You must prove you're not a robot