Form 1 Demographics

Attachment 6: DEMOGRAPHICS FORM

Web-based Skills Training for SBIRT (Screening Brief Intervention and Referral to Treatment)

November 2011

OMB # 0925-XXX

Expiration Date xx/xxxx

Public reporting burden for this collection of information is estimated to average less than 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Each time the assessment is completed, it is expected to be completed in a single sitting. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*).  Do not return the completed form to this address.

Demographics Questionnaire

1. Age

____ years
____ prefer not to answer

2. Gender

____ Male
­­____ Female
____ prefer not to answer

3. Are you Hispanic or Latino?

• Yes, Hispanic or Latino

• No, not Hispanic or Latino
  
  
  

What is your race?

• American Indian or Alaska Native

• Asian

• Black or African American 

• Native Hawaiian or Other Pacific Islander

• White

4. Location of practice:

_______ US Zip Code

5. Population of community in which your primary office is located:

____ Frontier
____ Rural
____ Suburban
____ Urban
____ Mixed

6. Please estimate the amount of time you spend in direct patient care.

____ hours per week

7. Number of years since you completed your clinical training program (including residency):_____

8. Primary clinical degree:_________

9. Profession:

____ Physician
____ Nurse Practitioner
____ Physician Assistant

10. Which of the following best characterizes your training regarding assessment and treatment of substance use problems?

 ____ Minimal
 ____ Slight
 ____ Moderate
 ____ Extensive

11. Which of the following best characterizes your experience with addressing substance use problems with patients?

 ____ Minimal
 ____ Slight
 ____ Moderate
 ____ Extensive

12. Have you ever participated in education or training activities for substance abuse or addictions?
____ No
____ Yes: If yes, please describe your formal education or training in substance abuse or addictions (check all that apply)

Undergraduate education included substance abuse or addictions in the curriculum
Medical or Graduate education included substance abuse or addictions in the curriculum
I have a certificate as a substance abuse or addictions specialist
Participated in CME/CEU training on substance abuse or addictions
Attended a lecture (1 hour or less) on substance abuse or addictions and approach to treatment
Participated in a training or conference (2 hours or more) on substance abuse or addictions treatment strategies
Interaction or training provided by State Department of Health

13. Have you ever participated in education or training activities for motivational interviewing?

____ No
____ Yes: Please describe your education or training in motivational interviewing (MI) (check all that apply)

Attended a presentation on MI (1-3 hours).
Attended a brief MI training (4-8 hours).
Attended a traditional MI training workshop (16 hours).
Been coached and received feedback about MI skills
Read any of Miller and Rollnick's books on MI (1991, 2002, or 2008).
Read journal articles about MI.
Watched any of the MI training videotapes.

8. Time since first exposed to MI:
   ____Years
   ____ Months 
   ____ I have not previously been exposed to MI

14. Please describe your formal education or training in tobacco dependence and treatment (check all that apply)

Undergraduate education included tobacco cessation in the curriculum
Graduate education included tobacco cessation in the curriculum
I have a certificate as a tobacco cessation specialist
Participated in CME/CEU training on tobacco use and treatment
Attended a lecture (1 hour or less) on tobacco use and approach to treatment
Participated in a training or conference (2 hours or more) on tobacco use treatment strategies
Interaction or office visit by a pharmaceutical company representative
Interaction or training provided by a State Department of Health

15. In general, how comfortable are you using a computer?

1. Very comfortable

2. Somewhat comfortable

3. Neutral

4. Somewhat uncomfortable

5. Very uncomfortable

16. How many hours per week do you spend using the computer, including work and leisure time?

1. none

2. up to 5 hours/week

3. between 5 and 10 hours/week

4. between 10 and 20 hours/week

5. More than 20 hours/week

17. Do you have internet access at home?

a. Yes, dial up

b. Yes, broadband (DSL, cable)

c. No