Methadone (Lvl 1), Suboxone, and Vivitrol Forms

Human Services Block Grant Data / Comparative Effectiveness Research (CER) Tracking

***Fill out a separate form for each type of medication***

Person filling out form - Contact information

First Name

Last Name

Phone

Provider Name

Select Month

Select Year

Please Choose the Medication

1 - Number of individuals residing in Dauphin County that have been enrolled in this specific medication-assisted treatment program for 90-179 days.

2 - Number of enrolled individuals (from entry made in box #1) that are free from illicit opioid use at each appointment during the first 90 days of his/her treatment as determined by a urine drug screen.

3 - Number of individuals enrolled for greater than 90 days (from entry made in box #1) that are currently enrolled in and actively attending counseling in conjunction with his/her medication-assisted treatment.

4 - Number of individuals residing in Dauphin County that have been enrolled in this specific medication-assisted treatment program for 180-364 days

5 - Number of individuals (from entry made in box #4) that are free from illicit opioid use as determined by a urine drug screen at each appointment from days 91 through 180 of his/her treatment

6 - Number of individuals enrolled for greater than 90 days (from entry made in box #4) that are currently enrolled in and actively attending counseling in conjunction with his/her medication-assisted treatment.

7 - Total number of individuals residing in Dauphin County that have been enrolled in this specific medication-assisted treatment program for greater than 365 days.

8 - Number of individuals (from entry made in box #7) that are free from illicit opioid use as determined by urine drug screens at each appointment from days 365 and ongoing.

9 - Number of individuals enrolled for greater than 365 days (from entry made in box #7) that are currently enrolled in and actively attending counseling in conjunction with his/her medication-assisted treatment.