1 Start 2 Complete 1. Have you attended a CHoSEN Forum in the past? Yes, I have attended a CHoSEN Forum in the past. No, this will be my first time attending a CHoSEN Forum. 2. Do you work in a healthcare (physical or behavioral) facility? If, NO - skip to question #9 - then proceed with remainder of evaluation. Yes No - Please scroll to question #9 - Primary Perspective you are Participating 3. Is your healthcare facility currently implementing CHoSEN QIC interventions? Yes, my healthcare facility is implementing CHoSEN QIC interventions. No, my healthcare facility is not yet implementing CHoSEN QIC interventions. No, but I am interested in learning more about CHoSEN QIC. I am unsure if my healthcare facility is engaged with CHoSEN QIC. 4. What type of healthcare services does your facility provide? Physical healthcare Behavioral healthcare 5. In what type of healthcare setting(s) do you work? Select all that apply Inpatient Outpatient Other - Please Specify 5. In what type of healthcare setting(s) do you work? Select all that apply Other - Please Specify 6. With which population(s) do you work? Select all that apply Adult Infant Pediatric Other - Please Specify 6. With which population(s) do you work? Select all that apply Other - Please Specify 7. Please select your healthcare facility Avista Adventist Hospital Campbell County Memorial Hospital Cheyenne Regional Medical Center Children’s Hospital Colorado, AMC Cody Regional Health Denver Health Medical Center Good Samaritan Medical Center Ivinson Memorial Hospital utheran Medical Center McKee Medical Center Montrose Medical Center North Colorado Medical Center North Suburban Medical Center Parker Adventist Hospital Parkview Medical Center Platte Valley Medical Center Presbyterian St. Luke's Medical Center Rose Medical Center Saint Joseph Hospital San Luis Valley Regional Medical Center Sheridan Memorial Hospital Sky Ridge Medical Center St. Vincent Healthcare St. Mary’s Medical Center Swedish Medical Center UCHealth Greeley Medical Center UCHealth Highlands Ranch Hospital UCHealth Longs Peak Hospital UCHealth Medical Center of the Rockies UCHealth Memorial Hospital UCHealth Parkview Medical Center UCHealth Poudre Valley Hospital UCHealth University of Colorado Hospital Valley View Hospital Wyoming Medical Center Other.. Please Specify 7. Please select your healthcare facility Other.. Please Specify 8. What is the NAME of your healthcare facility? 9. Which of the following best describes the type of position you hold? Care Coordinator Quality Improvement Staff Social Worker Nurse (RN, NP) Physician Physician Assistant/Nurse Practitioner Other Medical Provider - please specify: Other Non-Medical Personnel - please specify: Other = Please specify 9. Which of the following best describes the type of position you hold? Other = Please specify 10. From what primary perspective are you participating in this event? Academia and/or research Advocacy Behavioral healthcare Community-based family support organization Early intervention Early care and learning Education setting (K-12) Human services Lived experience related to substance use and pregnancy Lived experience related to caring for an individual prenatally exposed to substances Lived experience having a Fetal Alcohol Spectrum Disorder (FASD) or other impact(s) of prenatal substance exposure Medicaid state agency Physical healthcare Public health Quality improvement Substance use recovery support organization Substance use treatment organization or provider Youth serving organization Other - Please specify 10. From what primary perspective are you participating in this event? Other - Please specify 11. Which organization or entity do you represent? 12. What is your job title or role? 13. In which county(ies) do you engage in work related to substance use and pregnancy/families? (*Select all that apply.) If your work is statewide, please select 'Statewide'. If you work outside of Colorado, please select 'Outside of Colorado' and specify your geographic location. If you are not employed in a capacity that is related to substance use and pregnancy/families, please select the county/area in which you live. Statewide- Colorado Adams Alamosa Arapahoe Archuleta Aurora Baca Bent Boulder Broomfield Chaffee Cheyenne Clear Creek Colorado Springs Conejos Costilla Crowley Custer Delta Denver Dolores Douglas Eagle Elbert El Paso Fremont Garfield Gilpin Grand Gunnison Hinsdale Huerfano Jackson Jefferson Kiowa Kit Carson Lake La Plata Larimer Las Animas Lincoln Logan Mesa Mineral Moffat Montezuma Montrose Morgan Otero Ouray Park Phillips Pitkin Prowers Pueblo Rio Blanco Rio Grande Routt Saguache San Juan San Miguel Sedgwick Summit Teller Washington Weld Yuma Outside of Colorado - please specify. Other - please specify 13. In which county(ies) do you engage in work related to substance use and pregnancy/families? (*Select all that apply.) Other - please specify Leave this field blank
