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Title
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First Name
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Last Name
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Please enter your HOSPITAL name and address
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Hospital Name
Address1
Dept.
Address2
Mail Drop #
City
State
Zip Code
Telephone #
Fax #
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Please complete if you wish to receive surveys at your home address:
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Address
City
State
Zip Code
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Please check how you would prefer to have honorariums paid:
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Pay honorariums to hospital above
Pay honorariums directly to me
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Do you have access to the world wide web?
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Check if "Yes"
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May we contact you by email to present survey and honorarium opportunities?
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Check if "Yes"
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Please enter your email address:
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Is this your pharmacy email address or your home email address?
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Pharmacy email address
Home email address
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Are you a registered pharmacist?
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Check if "Yes"
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What year did you begin practicing as a pharmacist?
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What year did you begin with the pharmacy listed above?
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Number of staffed beds at your hospital:
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(Please do not guess if you do not know.)
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Number of full-time pharmacists at your hospital:
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Please check the type(s) of data/information you can provide:
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Inventory, Usage, Dispensing and Purchasing Information
Net Acquisition/Invoice Cost
Patient diagnosis data: # patients treated by diagnosis, drugs used, dosing information, etc.
Drug distribution volume (# vials, amps, etc.) to various departments from central pharmacy
Drug related information from other hospital departments (ex. Card Cath Lab, ER, etc.)
Opinions/Attitudes/Perceptions
Formulary Status
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Estimated total DAILY pharmacy Rx order volume:
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# Rx orders/day
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Were you referred to our site by another pharmacist?
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Check if "Yes"
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If yes, what is the ID number of the pharmacist who referred you to our site?
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