The code block below illustrates how one might use # and // as comments in your logic and calculations.

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This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

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Required format:

eIuronZef7IcygwwRTetv4LAg6yNwvp2wfTnwspYICPcdIqMHZtP

VT RETAIN Practice Enrollment Form

1. Practice Name:

* must provide value

2. Type of Practice:

* must provide value

Please describe other type of practice

First name of the RETAIN contact person for the practice:

* must provide value

Last name of the RETAIN contact person for the practice:

* must provide value

Phone number of the RETAIN contact person for the practice:

* must provide value

Fax number for RETAIN communication with the practice:

Email address for RETAIN communication with the practice:

* must provide value

Title or position of RETAIN contact person for the practice:

Preferred method for RETAIN to contact the practice:

Telephone

Fax

Other

If other, please describe:

Preferred time(s) for RETAIN to contact the practice:

Practice Street Address:

* must provide value

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Practice City/Town:

* must provide value

State

* must provide value

Zip Code:

* must provide value

Practice Mailing Address (if different from street address):

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Practice website:

4. About how many patients does the practice serve?

* must provide value

< 2,000

2,000 - 2,999

3,000 - 3,999

4,000 - 4,999

5,000 - 6,999

7,000 - 8,999

>9,000

5. Screening Method
We use an electronic survey that can be accessed directly by the patient either at registration or rooming. Some practices use a tablet, others direct their patients to card or poster with link and QR code, and some use a paper form. What is your preferred method for screening all patients for risk of work disability?

Tablet

Link and QR code for use with patient's mobile phone

Paper form

Prefer to discuss with VT RETAIN before selecting

Other

Please describe:

How many tablets will you need?

Would you like to:

Fax paper screening forms back to VT RETAIN (secure fax #:603-676-4209)

Have them picked up by the VT RETAIN team

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Approximately how many patients will you see per day?

6. Other than English, what are the most common languages spoken by patients in your clinic?

Spanish

Chinese

French

Vietnamese

German

Nepali

Swahili

Arabic

Somali

Other (Specify)

Other languages

7. How would you prefer to receive your free provider Category 1 provider CME (1.0)?

In person

Live video

Link to pre-recorded video

Prefer to discuss with VT RETAIN before selecting

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Please indicate preferred date and time (if known):

M-D-Y H:M

Please note preferred date and time:

M-D-Y H:M

8. VT RETAIN offers free Work-Health Coach training to care managers in enrolled primary care offices. This is not a requirement to participate in VT RETAIN, rather it is an option for practices interested in developing this expertise within their own clinic. Training involves didactic sessions, weekly case reviews, self-directed learning, and mentoring from a VT RETAIN Work-Health Coach and can be tailored to meet the needs of the participating clinic. The goal is to develop skills to prevent work disability early in the patient’s injury or illness process. VT RETAIN can provide up to 0.20 FTE to support embedded care managers in this role depending on their preferred level of involvement.

Would you like VT RETAIN to train your embedded care manager(s) to serve as a Work-Health Coach?

Yes

Prefer to discuss with VT RETAIN before selecting

Name of care managers who want SAW/RTW training (if known):

Contact info of care managers who want SAW/RTW training (if known):

Job title(if known)

Credentials (if known)

Pay rate (if known)

Fringe rate (if known)

Indirect cost rate (if any):

9. How do your providers want to receive information from our Work-Health Coaches (check all that apply)?

Patient return-to-work plan and discharge summary

Monthly updates from the Work-Health Coach working with your patients

Each provider will make their own personalized plan with their Work-Health Coach

Coach-access to our Electronic Medical Record (EMR) for staff messaging and chart review

Other

Prefer to discuss with VT RETAIN before selecting

For coach-access to our Electronic Medical Records (EMR), we prefer to use:

Own EMR agreement

The VT RETAIN EMR agreement

Prefer to discuss with VT RETAIN before selecting

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Please describe:

10. The VT RETAIN study is open to patient enrollment. What is the earliest date that your practice can start screening patients? (Exact start date depends on multiple factors and may vary.)

January 5, 2022

After January 5,2022

Prefer to discuss with VT RETAIN before selecting

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10a. The VT RETAIN study is open to patient enrollment. We would like to have all practices enrolled by June, 2022. What is the earliest date that your practice can start screening patients? (Exact start date depends on multiple factors and may vary)

Preferred start date (if known):

Prefer to discuss with VT RETAIN before selecting

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Preferred start date (if known):

M-D-Y

11. RTW services provided by the practice (check all that apply):

* must provide value

Vocational counseling

Vocational rehabilitation

Vocational retraining

Physical functional capacity evaluations

Cognitive functional capacity evaluations

Job simulation

Embedded rehabilitation (e.g. physical therapy, occupational therapy)

Embedded behavioral health services

Medication assistance for substance use disorders

Embedded care management

Same day or urgent care appointments

Telemedicine/telehealth visits

None

Other

If other please describe:

12. Please check all that apply to your practice:

We are a Federally Qualified Health Center

We accept workers' compensation insurance

We accept Medicare/Medicaid

Other

If other please describe:

Please provide the name and contact information for the financial contact in your practice (if different from the RETAIN contact)
Name:

Contact information of the financial contact in your practice.

13. Any other information or comments you would like to provide (optional):

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Date of entry:

* must provide value

M-D-Y

Thank you for enrolling. We look forward to working with you!
- The VT RETAIN Team

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

VT RETAIN Practice Enrollment Form

Thank you for enrolling. We look forward to working with you! - The VT RETAIN Team

You have selected an option that triggers this survey to end right now.

Thank you for enrolling. We look forward to working with you!
- The VT RETAIN Team