Pharmacy expression of interest form: EXPAND-C

Pharmacy expression of interest form: EXPAND-C

Thank you for your interest in the EXPAND-C project led by Burnet Institute. Please complete this form so we can learn more about your pharmacy and how you could fit with the program.
Do you dispense Opioid Agonist Therapy (OAT)?*

YesNo
How many customers do you currently have on OAT?*
EXPAND-C offers two models, one model is avaliable at pharmacies located in metropolitan Melbourne and surrounds and involves a Burnet project nurse facilitating hepatitis C testing and follow up from your pharmacy. The other model invoves pharmacists themselves facilitating testing and follow up (with support from Burnet). Please read the website for details and select which you are most interested in.
What model of EXPAND-C is your pharmacy interested in participating in?*

Burnet nurse based in pharmacyPharmacist led testing

Do you have a private space where a study nurse can conduct all of the activities in the list below?*

YesNo
As part of the project, a study nurse will:
- discuss hepatitis C (HCV) with interested people
- obtain informed consent
- perform fingerstick HCV antibody testing
- perform venepuncture if HCV antibody is detected
- perform hand hygiene (requires access to hand basin).

The EXPAND-C pharmacist-led testing and referral model involves participating pharmacists undertaking compulsory training in study procedures, INSTI® point of care hepatitis C Antibody test and good clinical practice. This training will take approx 2 hrs in addition to the ongoing time for being involved.
Are pharmacists able to commit to time involved in training and study procedures?*

YesNo
To participate, pharmacies must have a private space where pharmacistis can:

• discuss hepatitis C (HCV) with interested people
• obtain informed verbal consent from clients to participate in the study
• perform fingerstick HCV antibody testing
• perform hand hygiene (requires access to hand basin)
Does your pharmacy have a space appropriate for all the activities listed above?*

YesNo

The EXPAND-C model where a Burnet project nurse is based at the pharmacy requires less time committment from the pharmacist. If you have a private space where a nurse can conduct study activities you may wish to consider this model.

If so, please resubmit this form. If not, please continue below.
Would you like to be kept in the loop for other community pharmacy initiatives?*

Yes, via emailYes, via phoneNo
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please click 'Submit' below to save your preference.

Thank you for your interest however for this project we are seeking community pharmacies that dispense OAT.
Would you like to be kept in the loop for other community pharmacy initiatives?*

Yes, via emailYes, via phoneNo
Email*
example@example.com
Phone*
Include area code if landline
Please click 'Submit' below to save your preference.

Unfortunately we can only offer the project at pharmacies that have a dedicated private space at this time.
Would you like to be kept in the loop for other community pharmacy initiatives?*

Yes, via emailYes, via phoneNo
Email*
example@example.com
Phone*
Include area code if landline
Please click 'Submit' below to save your preference.

Your contact details
Contact pharmacist name*
Name
Pharmacy name*
Pharmacy name
Pharmacy Postcode *
Postcode where pharmacy located
Phone*
Include area code if landline
Email*
example@example.com
How would you prefer to be contacted?*

PhoneEmail
Preferred day/s and time/s to contact you
Days and times
Any additional comments?
Comments
Would you like to be kept in the loop for other community pharmacy initiatives in the future?*

YesNo
Should be Empty:

Your contact details