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1:1 Educational Session

First Name

Last Name

Email

Phone

Pronouns

Position Title

Organization

Preferred dates & times for brief (10-30 minutes) one-on-one educational session * Required

Tuesdays, 9am-12pm

Tuesdays, 12pm-1pm (Lunch)

Tuesdays, 1pm-4pm

Wednesdays, 1pm-4pm

Fridays, 1pm-4p

Other (Please specify in last box on form)

What topics would you like to address during this session?

About how many patients do you currently prescribe buprenorphine to?

How would you prefer to have your session? * Required

Virtual

In Person

Is there anything else you would like the CIAO team to know before your session?

How did you hear about CIAO?

Thanks for submitting! You will receive an email from the CIAO team soon about your session.

CENTER FOR INNOVATION IN ACADEMIC DETAILING ON OPIOIDS AND STIMULANTS

Center on Substance Use and Health

San Francisco Department of

Public Health

25 Van Ness Avenue, Suite 500
San Francisco, CA 94102

Seal of the city and county of san francisco

ciao.sf@sfdph.org

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CIAO is a program of the San Francisco Department of Public Health in collaboration with the CDC.

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