1. Are you a practicing Pulmonary or Infectious Diseases provider in the U.S.?YesNo 2. Do you plan to prescribe the home sputum kit for a patient that lives in the state of New York?Yes (regulatory restrictions prevent us from testing patients from the state of New York at this time) No3. I consider myself experienced in dealing with individuals suspected or confirmed to have NTM lung disease.Strongly AgreeAgreeNeutralDisagreeStrongly Disagree4. Do you agree to participate in a maximum of 2 anonymous surveys administered and designed by the COPD Foundation and other partners with the aim to assess impact and challenges of the process improvement pilot program? The survey results will inform potential national implementation of such a program.YesNo Thank you for your interest in this pilot. You have qualified to participate and will receive an email containing a prescription order form within the next 2 business days. We ask that prior to prescribing any home testing kits, you complete the first of two anonymous surveys aimed at assessing the utility of our pilot program, which will also be attached to the aforementioned email. Full NameEmail AddressInstitutionState Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip CodePhonePhone NumberProfessional Credentials MD DO NP PA RT RN PT EP RPh Other Other CredentialsI am a human.Additional Thank you for your interest in this pilot. Unfortunately, due to one or more of your responses, you are ineligible to participate in our pilot at this time. Please contact our Bronchiectasis and NTM Information Line at 1-833-411-LUNG (5864) or email us at info@BronchiectasisAndNTMinitiative.org if you have questions about your eligibility.
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