The Greater Washington Partnership for Palliative and End-of-Life Care
Feedback Form -
Opioid Stocking Issue
Feedback Form for Opioid Stocking Issue
The Greater Washington
Partnership for Palliative
and End-of-Life Care:



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Information:






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The Greater Washington Partnership (GWP) is investigating the issue of opioids not
being stocked adequately in low income neighborhoods.  To assist us in our research,
we would appreciate your assistance by completing the form below if you or your
patients have experienced an issue with opioid stocking at your local pharmacy.  This
information is for research purposes only and will remain strictly confidential.  All fields
are required.  Thank you for your time and assistance in helping us to resolve this
issue.
Name of the organization
completing form
Name of the person completing
form
Origin of prescription                       
(i.e. hospital, emergency room, general practitioner)
Illness
Prescription Name
Pharmacy Name
Pharmacy Address
Pharmacy Zip Code
Reason given for not being able
to fill prescription