Thank you for your interest in participating in the NAADAC
Practitioner Research Network Questionnaire.
Please enter the following information to begin the survey:
First Name*
Last Name*
E-mail address* (or a PIN number at least 5 digits long, if you don't have e-mail)
ZIP code*
Date of Birth*   Year:

This information is being collected in order to determine whether your participation in the survey is as a randomly selected participant or a voluntary respondent.  Your e-mail address is used for tracking purposes only and your personal information will never be given to a third party.

YES   NO Did you receive a letter requesting your participation in this study?


© 2000 The Lewin Group. All rights reserved.
Revised: June 15, 2000