1 Start 2 Complete

Information About You

For the following questions, please indicate your response by checking the appropriate box or writing your answer in the space provided.

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Check all that apply.
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Check all that apply:

WHAT YOU KNOW ABOUT OPIOID-RELATED ISSUES

 

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Check all that apply.
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YOUR ACTIONS IN THE PAST 6 MONTHS

Instructions: Thinking of opportunities you may have had in the past 6 months, please rate how frequently or infrequently you provided the following opioid-related services when the opportunity presented itself from 0-20%, 21-40%, 41-60%, 61-80%, or 81-100% of the time.

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0-20% of the time21-40% of the time41-60% of the time61-80% of the time81-100% of the timeNo Opportunities / Not Applicable
Screened or assessed someone for potential opioid use disorder (OUD) or opioid overdose risk
Educated people about OUD
Provided education or counseling to family or caregivers regarding OUD
Prescribed, dispensed, or discussed specialized treatment or rehabilitation facilities for a person with OUD
Prescribed, dispensed, or discussed cognitive behavioral therapy for OUD
Prescribed, dispensed, or discussed medication assisted treatment for OUD
Prescribed, dispensed, or discussed naloxone
Spoke with another healthcare provider on someone’s behalf

YOUR ABILITIES, BELIEFS, AND READINESS

Instructions: On a scale of 1 to 7, please rate your level of agreement or disagreement with the following statements, with 1 being strongly disagree to 7 being strongly agree.

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Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree
I already have enough information about how to manage an overdose
I am already able to administer naloxone to someone who has overdosed
I would be able to check that someone who has overdosed was breathing properly
I am going to need more training before I would feel confident to help someone who has overdosed
I would be able to perform mouth-to-mouth resuscitation on someone who has overdosed
I would be able to perform chest compressions on someone who has overdosed
If someone overdoses, I would know what to do to help them
I would be able to place someone who has overdosed in the recovery position
I know very little about how to help someone who has overdosed
I would be able to deal effectively with an overdose
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Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree
I would be afraid of giving naloxone in case the person becomes aggressive afterwards
I would be afraid of doing something wrong in an overdose situation
I would be reluctant to use naloxone for fear of precipitating withdrawal symptoms
If I tried to help someone who has overdosed, I might accidentally hurt them
I would feel safer if I knew that naloxone was around
I would be afraid of suffering a needle stick injury if I had to give someone a naloxone injection
Needles frighten me, and I wouldn’t be able to give someone an injection of naloxone
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Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree
Everyone at risk of witnessing an overdose should have naloxone
I couldn’t just watch someone overdose, I would have to do something to help
If someone overdoses, I would call an ambulance, but I wouldn’t be willing to do anything else
Family and friends of drug users should be prepared to deal with an overdose
If I saw an overdose, I would panic and not be able to help
If I witnessed an overdose, I would call an ambulance immediately
I would stay with the overdose victim until help arrives
If I saw an overdose, I would feel nervous, but I would still take the necessary actions
I will do whatever is necessary to save someone’s life in an overdose situation
If someone overdoses, I want to be able to help them