Great Lakes Physicians Clinical Experience B

Fetal Alcohol Spectrum Disorders Regional Training Centers

E14_Great Lakes FASD RegionalTraining Center Clinical Experienc

Great Lakes Physicians Clinical Experience B

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E14. Great Lakes FASD Regional Training Center

Clinical Experience B Evaluation Form


Please review and respond to the questions below. Your responses are essential to us as we work to make our training activities as meaningful as possible. Your responses will be treated confidentially.


1. On a scale from 1-10 where 1 means “Not confident in my skills” and 10 means

Totally confident in my skills,” how confident are you in your skills to recognize and assess FASD in your patient population.

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1a. If you did not rate yourself a “10”, what would need to happen for you to

give yourself that rating? Please check all that apply.


 I need a better understanding of FASD concepts

 I need better skill at diagnosing

 I need more support from colleagues

 I need more information about where to refer a patient

 I need more time for a patient appointment

 I need to feel more comfortable bringing up the topic to patients and

family members

  • I need to feel more comfortable brining up the topic to colleagues

  • I need more practice

  • I’d rather refer

  • Other: ­

­ ­______

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2. On a scale of 1-10 where 1 means “Not at all Ready” and 10 is “Totally Ready,” how ready are you at the present time to include clinical assessment in your professional practice.


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3. On a scale of 1-10 where 1 means “I am not likely to include clinical assessment for FASD” and 10 means “I am very likely to include clinical assessment for FASD.” How likely are you to include FASD assessment with your patient population?



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3a. If you did not rate yourself a “10”, what would need to happen for you to

give yourself that rating? Please check all that apply.


 I need a better understanding of FASD concepts

 I need better skill at diagnosing

 I need more support from colleagues

 I need more information about where to refer a patient

 I need more time for a patient appointment

 I need to feel more comfortable bringing up the topic to patients and

family members

  • I need to feel more comfortable brining up the topic to colleagues

  • I need more practice

  • I’d rather refer

  • Other:

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  1. On a scale of 1-10 where 1 means “Very Poor” and 10 means “Excellent,” how would you rate the clinical preceptorship you have just received in assessing Fetal Alcohol Spectrum Disorders (FASD)?



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  1. What suggestions do you have for improving this training?


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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

If you are a PROFESSIONAL, please circle the one that best represents your current position:


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)




THANK YOU for your participation in our Great Lakes

FASD Regional Training Center Clinical Training

Date Entered:__________________

By__________________________


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleGreat Lakes FASD Regional Training Center Skills Survey A
Authorgwilton
File Modified0000-00-00
File Created2021-01-30

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