2016 Ipop Application

The application asks for information about the opioid overdose problem in your community or state, and your current ideas for how you anticipate influencing the problem using policy, systems and/or environmental change strategies. Please be sure to include who you are intending to bring as part of your team.

Please provide us with the following information:

Name
Organization Name
Your Role
Email
Work Phone
City
State

Will a team attend the workshop with you?

___ Yes(Please Note:If “Yes,” that each team can have a maximum of four (4) people)

___ No

Describe the opioid overdose problem you want to address, and provide us with some key statistical summary information from reports or surveillance systems. (Please include the sources for your information.)

Geographically describe the location (i.e., section of the state/county/city) of the opioid overdose problem, which might also be the area where you want to focus a project.

Partner Information

Multiple stakeholders might be interested in the opioid overdose problem in the location you have described. Some of the stakeholders might be willing to collaborate with you on a project.To help us understand your partnership possibilities, please list up to five current partners (or anticipated future partners) for your project.

First Partner Name (if available):

Relationship:

___ Current Project Partner

___ Possible Future Partner

Organization partner works with:

Briefly describe what they (or organization) can/could contribute:

Partner's email (if available):

Will they be attending the workshop with you?

___ Yes

___ No

___ Uncertain

Do you have another current or future partner to add?

___ Yes

___ No

Second Partner Name (if available):

Relationship:

___ Current Project Partner

___ Possible Future Partner

Organization partner works with:

Briefly describe what they (or organization) can/could contribute:

Partner's email(if available):

Will they be attending the workshop with you?

___ Yes

___ No

___ Uncertain

Do you have another current or future partner to add?

___ Yes

___ No

Third Partner Name (if available):

Relationship:

___ Current Project Partner

___ Possible Future Partner

Organization partner works with:

Briefly describe what they (or organization) can/could contribute:

Partner's email(if available):

Will they be attending the workshop with you?

___ Yes

___ No

___ Uncertain

Do you have another current or future partner to add?

___ Yes

___ No

Fourth Partner Name (if available):

Relationship:

___ Current Project Partner

___ Possible Future Partner

Organization partner works with:

Briefly describe what they (or organization) can/could contribute:

Partner'semail(if available):

Will they be attending the workshop with you?

___ Yes

___ No

___ Uncertain

Do you have another current or future partner to add?

___ Yes

___ No

Fifth Partner Name (if available):

Relationship:

___ Current Project Partner

___ Possible Future Partner

Organization partner works with:

Briefly describe what they (or organization) can/could contribute:

Partner'semail(if available):

Will they be attending the workshop with you?

___ Yes

___ No

___ Uncertain

RELEVANT POLICY/SYSTEMS

Policy, system and environmental change interventions can vary by state. Here is a brief description of two opioid overdose interventions in North Carolina.

Policy change: In an attempt to increase the number of physician providers using the state’s prescription drug monitoring system, the state legislature passed a law permitting additional personnel in a doctor’s office to access the system.

Systems change: Later, because enrollment numbers were still not ideal, a few state agencies collaborated on a systems change effort to simplify the registration and approval process for users of the system.

For the opioid overdose problem you listed as your target area, briefly list some of the existing local or state policies/systems/environments that are relevant but fail to address the problem in the location where you want to focus.

Have you identified any policy, system, or environmental solutions to pursue?

___ Yes

___ No

Tell us a little about the current political climate for the policy/system/environmental change(s) you are considering?

What opportunities or circumstances might support your efforts at policy/system/environmental change?

What current or future barriers might impede your efforts at policy/system/environmental change?