Form Approved
OMB No. XXXX-XXXX
Exp. Date xx/xx/xxxx
Month of your birthday ___ ___
Last 2 digits of your social security number ___ ___
Identification and Treatment of FASD Post-Training Evaluation
Please circle the BEST answer for each of the following: |
Staff Use Only |
The best public health message related to alcohol consumption by women of childbearing age is:
|
1 (I-C) |
Scientific studies of the effects of alcohol on the fetus have shown that: a. Alcohol has no effect on the development of the fetus in the third trimester. b. Alcohol can only affect fetal development in the first trimester. c. A small to moderate amount of alcohol is safest during the second trimester. d. Of all the different types of alcohol, wine is the safest for a pregnant woman to consume. e. None of the above is correct. |
6 (IV-C) (I) |
Although specific deficits experienced by individuals with an FASD vary widely, behavioral deficits are likely to include which of the following:
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7 (V-C) |
Which of the following include all three facial abnormalities associated with fetal alcohol syndrome?
|
8 (V-C) |
Which of the following is NOT required to confirm a diagnosis of fetal alcohol syndrome (FAS)?
|
9 (V-C) (I) |
A variety of strategies have been found to be effective when working with individuals with an FASD. Which one of the following may not be as effective?
|
10 (VI-C) |
1 (over)
The public reporting burden of
this collection of information is estimated to average 13 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. 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 - CDC/ATSDR
Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333 ATTN: PRA (XXXX-XXXX)
1 (over)
2. In your current position, do you provide services to women of childbearing age?
YES NO
3. On a scale of 0 to 10 where 0 means, “Not confident in my skills” and 10 means “Totally confident in
my skills,” how confident are you in your skills to do the following? (circle one number per row)
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NOT Confident in my skills |
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TOTALLY Confident in my skills |
a. Screen women for risky or hazardous drinking |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
b. Educate pregnant women about the effects of alcohol on their babies |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
c. Conduct brief interventions for reducing alcohol consumption |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
d. Utilize resources to refer patients who need formal treatment for alcohol abuse |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
4. In your current position, do you provide services to individuals who may be at risk of an FASD?
YES NO
5. On a scale of 0 to 10 where 0 means, “Not confident in my skills” and 10 means “Totally confident in my skills,” how confident are you in your skills to do the following? (circle one number per row)
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NOT Confident in my skills |
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TOTALLY Confident in my skills |
a. Identify persons with possible FAS or other prenatal alcohol-related disorders |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
b. Diagnose persons with possible FAS or other prenatal alcohol-related disorders |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
c. Utilize resources to refer patients for diagnosis and/or treatment services |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
d. Manage/coordinate the treatment of persons with FASDs |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
2 (continue)
6. How will you use the information you received during the training today?
7. What additional information do you need to make changes in your practice?
8. What additional comments do you have about this training?
To what extent to you agree with the following statements? |
Strongly disagree |
Disagree |
Neither Agree nor Disagree |
Agree |
Strongly agree |
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5 |
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The instructor seemed knowledgeable about the topics. |
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TRAINER 1 (NAME) |
1 |
2 |
3 |
4 |
5 |
TRAINER 2 (NAME) |
1 |
2 |
3 |
4 |
5 |
9. We would like to know your thoughts about this training/presentation. Please circle the number that most clearly represents the extent to which you agree with each of the following statements.
3 (over)
Please take a moment to tell us about yourself: |
||
Are you (Circle one): 1=Male 2=Female 3=Transgender
In which State do you provide services? 1=Wisconsin 2=Michigan 3=Indiana 4=Ohio 5=North Carolina 6=Minnesota 7=Hawaii 8=Other Specify ______________________ (8a)
Are you Hispanic or Latino(a)? 1=Yes 2=No
How would you describe your race? (Select all that apply) 1=American Indian/Alaska Native 2=Asian 3=Black or African American 4=Native Hawaiian or other Pacific Islander 5=White
Are you a parent/caregiver of a child with FAS/FASD? 1=Yes 2-No |
THANK YOU!
PHYSICIAN 1=OB/GYN 2=Geneticist 3=Pediatrician 4=Psychiatrist 5=Family Physician 6=Internist 7=Preventive Medicine 8=Occupational Medicine 9=Addiction Medicine 10=Physician, other Specify ____________(10a) OTHER MEDICAL 11=Dentist 12=Physician Assistant 13=Nurse (NP, RN, LPN) 14=Other Medical Specify _____________(14a) ALLIED HEALTH 15=Psychologist (unspecified) 16=Rehabilitation Psychologist 17=Clinical Psychologist 18=Community Psychologist 19=Counselor (including AODA Counselor) 20=Social worker 21=OT/PT/SLP 22=Medical Technologist 23=Other allied health professional: Specify _____________ (23a)
OTHER 24=Public Health 25=Special Educator 26=Other Educator 27=Administrator 28=Corrections 29=Lawyer/Judge 30=Scientist 31=Prevention 32=Other: Specify ______________ (32a) |
If you are a STUDENT OR RESIDENT, please circle all that apply:
MEDICAL AND NURSING STUDENTS 1a=Med 1 1b=Med 2 1c=Med 3 1d=Med 4 1e=Clerkship 1f=Preceptorship 2=Nursing 3=Dental
ALLIED HEALTH 4=Allied Health (inc. OT/PT SLP/Social Work, Counseling, etc.)
RESIDENT 5=OB/GYN 6=Genetics 7=Pediatric 8=Psychiatry 9=Family Medicine 10=Internal Medicine 11=Preventive Medicine 12=Occupational Medicine 13=Addiction Medicine 14=Dental 15=Other resident: Specify ________ (15a)
OTHER STUDENT 16=Pre-doctoral student 17=Graduate Student 18=Undergraduate Student 19=Other Specify _______ (19a)
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | RMS397 |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |