FASD Pre-training survey - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Pre-Training Survey

You are invited to take part in a survey for health professionals. This survey is being conducted on behalf of the Centers for Disease Control and Prevention (CDC). The purpose of this survey is to understand the opinions and practices of health professionals around their patients’/clients’ alcohol use and on the prevention, identification, and treatment of fetal alcohol spectrum disorders. Your feedback is important as it will help assess the efficacy of trainings and identify the needs of health professionals to better address the services they provide to patients/clients around alcohol consumption and/or the effects of alcohol use during pregnancy.

This survey will take approximately 9 minutes to complete and your responses will be kept secure. You will be assigned a unique identity code which will be used to invite you to take a similar survey after six months to assess how useful this training has been in your practice with your patients/clients regarding their alcohol use. ICF International and Westat are the contractors hired by CDC to conduct and analyze the surveys, respectively. Any information you provide will be presented in aggregate in a report and no individual identifying information will be included.

Risks to participating in this survey are minimal and include the risk of your information becoming known to individuals outside the CDC, ICF International, and Westat. There will be no costs for participating, nor will you benefit from participating. Your participation in this survey is voluntary. You may decline to answer any question and you have the right to stop the survey at any time.

If you have any comments or questions about the survey, you can contact Melanie Chansky at melaniechansky@westat.com or at 301-517-4019.

Thank you.

1. I found out about this training from: (Check all that apply.)

• A professional organization…………>CONTINUE TO Q2

• A recognized leader in my field……..>GO TO Q4

• A colleague at my practice setting….>GO TO Q4

• Other, please specify __________________....>GO TO Q4

2. Please provide name of the professional organization from which you found out about this training ______________________

3. How did you find out about this training from the professional organization? (Check all that apply.)

• Website

• Email

• At a conference

• Other, please specify __________________

4. Fetal alcohol spectrum disorders are: (Check only one response.)

• Disorders a pregnant woman experiences when she drinks alcohol.

• Disorders that affect the ability of a pregnant woman who drinks alcohol to go full term.

• Physical disorders that affect a fetus when a pregnant woman drinks alcohol.

• The range of effects that can occur in an individual who was exposed prenatally to alcohol.

5. The effects of FASDs are always visible. (Check only one response.)

• True

• False

• Don’t know

6. FASDs are certain to be prevented when: (Check only one response.)

• a woman quits drinking as soon as she knows she is pregnant.

• a woman who is pregnant or may become pregnant does not consume alcohol.

• a woman does not take drugs other than alcohol during her pregnancy.

• a woman stops drinking once she starts breastfeeding her baby.

7. Which of the following are the primary facial dysmorphic features associated with Fetal Alcohol Syndrome? (Check all that apply.)

• Wide inner canthal distance

• Short palpebral fissures

• Full lips

• Smooth philtrum

• Thin upper lip

• Flaring nares

• Don’t know/unsure

8. What advice would you give your patient/client about how much alcohol is safe to drink during pregnancy? (Check only one response.)

• One glass of wine per day

• One light beer per day

• One shot of hard alcohol per day

• There is no known safe amount of alcohol consumption during pregnancy.

9. When is it safe to drink alcohol during pregnancy? (Check only one response.)

• During the first three months

• During the last three months

• Once in a while

• Never

10. What is the most effective strategy to reduce fetal alcohol spectrum disorders (FASDs)? (Check only one response.)

• Enact laws and other policy strategies that punish pregnant women for drinking alcohol.

• Screen all women of child bearing age for alcohol use and provide intervention as appropriate.

• Tell women who you think may have a drinking problem to get help.

• Conduct health fairs and other educational events for new mothers that focus on binge drinking.

11. Are you currently a/an (Check only one response):

• Student .……………….> GO TO Q28

• Resident ……………….> CONTINUE TO Q12

• Medical or Allied Health Professional (e.g., medical assistant, nurse, physician, social worker) …………………> CONTINUE TO Q12

• Other Professional …...> GO TO Q19

12. When do you (or someone in your practice) ask your patients/clients or their parents/caregivers about their alcohol use? (Check only one response.)

• Never

• Annually

• At each visit

• When indicated (please describe: ____________________)

• Other, please specify____________

13. My practice has a consistent process to screen or obtain information from all patients/clients about their alcohol use. (Check only one response.)

• Yes………………………> CONTINUE TO Q14

• No……………………….> GO TO Q19

• Don’t Know……………..> GO TO Q19

• Not applicable to the patients/clients in my practice setting………………>GO TO Q19

14. What does initial patient/client screening for alcohol use consist of in your practice setting? (Check only one response.)

• Informal questions (Do you drink? How often/much do you drink?, etc.).

• Formal screening tool or evidence-based/ validated screening instrument (AUDIT, AUDIT-C, DAST, CAGE, CRAFFT, NIAAA Youth Alcohol Screen, etc.).

• I don't know.

15. Who generally conducts the initial screening for alcohol? (Check all that apply.)

• Nurse (including nurse practitioner)

• Social worker

• Behavioral health specialist (coach)

• Psychologist

• Physician

• Physician’s Assistant

• Medical Assistant

• Other, please specify ____________________

16. Is screening for alcohol use followed by some type of intervention in your practice setting? (Check all that apply.)

• No, there is no patient/client education or intervention done following the initial screening…….>GO TO Q19

• Yes, all patients/clients are given educational materials/information on “safe” levels of alcohol and health risks associated with consuming too much alcohol ....> CONTINUE TO Q17

• Yes, patients/clients who screen positive for risky alcohol use are asked follow-up questions and provided brief counseling. …….....> CONTINUE TO Q17

• Yes, patients/clients who screen positive for risky alcohol use are asked follow-up questions and provided with additional resources (e.g., a list of treatment and/or counseling services in the community). .…….....> CONTINUE TO Q17

• Not sure if there is an intervention following the initial screening. …….GO TO Q19

17. Who generally does the intervention in your practice setting? (Check all that apply.)

• Nurse (including nurse practitioner)

• Social worker

• Behavioral health specialist (coach)

• Psychologist

• Physician

• Physician’s Assistant

• Medical Assistant

• Other, please specify _________________

18. Does your practice bill for screening and brief intervention services? (Check only one response.)

• Yes

• No

• Not sure

19. In your current position, do you provide services to individuals who may have fetal alcohol spectrum disorders (FASDs)? (Check only one response.)

• Yes

• No

• Not sure

20. On a scale from 1 to 5 where 1 means you strongly disagree with the statement and 5 means you strongly agree, to what extent do you disagree or agree with the following statements. (Select one number per row).

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
It is important to routinely screen all patients/clients for alcohol use	1	2	3	4	5
Screening a person for alcohol use confers a stigma to the person being screened	1	2	3	4	5
It is important to screen all pregnant women for alcohol use	1	2	3	4	5
It is important to screen all women of reproductive age for alcohol use	1	2	3	4	5
It is important to educate women of reproductive age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
It is important to inquire about and document potential prenatal exposure for all pediatric patients	1	2	3	4	5
Diagnosis of one of the FASDs may confer a stigma to a child and/or his or her family	1	2	3	4	5

21. Are you a Resident or Medical/Allied Health Professional (e.g., medical assistant, nurse, physician, social worker)?

• Yes……………….> CONTINUE TO Q22

• No...………………> GO TO Q24

22. On a scale from 1 to 5 where 1 means you are not confident in your skills and 5 means you are totally confident in your skills, how confident are you in your skills to do the following? (Select one number per row).

	Not at all confident in my skills	Slightly confident in my skills	Moderately confident in my skills	Very confident in my skills	Totally confident in my skills
Asking women, including pregnant women, about their alcohol use	1	2	3	4	5
Having a conversation with patients/clients who indicate risky alcohol use	1	2	3	4	5
Educating women of childbearing age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
Conducting brief interventions for reducing alcohol use	1	2	3	4	5
Utilizing resources to refer patients/clients who need formal treatment for alcohol abuse	1	2	3	4	5
Inquiring about potential prenatal alcohol exposure for my patients/clients	1	2	3	4	5
Identifying persons who may have one of the FASDs	1	2	3	4	5
Diagnosing persons who may have one of the FASDs	1	2	3	4	5
Referring patients/clients for diagnosis and/or treatment services for an FASD or alcohol use disorder	1	2	3	4	5
Managing/coordinating the treatment and care of persons who have one of the FASDs	1	2	3	4	5

23. Are you a Resident?

• Yes……………….> GO TO Q27

• No...………………> CONTINUE TO Q24

24. Please check the response that best represents your current position:

PHYSICIAN

• OB/GYN

• Geneticist

• Pediatrician/pediatric sub-specialist

• Psychiatrist

• Family Physician

• Internist

• Preventive Medicine

• Occupational Medicine

• Addiction Medicine

• Physician, other, please specify ____________

OTHER MEDICAL

• Dentist

• Physician Assistant

• Medical Assistant

• Nurse (NP, RN, LPN)

• Other Medical, please specify _____________

ALLIED HEALTH

• Psychologist (unspecified)

• Rehabilitation Psychologist

• Clinical Psychologist

• Community Psychologist

• Counselor (including AODA Counselor)

• Social worker

• OT/PT/SLP

• Medical Technologist

• Other allied health professional, please specify _____________

OTHER

• Public Health Specialist

• Special Educator

• Other Educator

• Administrator

• Corrections

• Lawyer/Judge

• Scientist

• Prevention Specialist

• Other, please specify ______________

25. In what year did you complete your professional training (e.g., medical residency, internship)?

_________

26. Are you interested in receiving CEUs/CMEs?

• Yes

• No

GO TO Q29

27. Please check the response that best represents your current residency training.

• OB/GYN

• Genetics

• Pediatric

• Psychiatry

• Family Medicine

• Internal Medicine

• Preventive Medicine

• Occupational Medicine

• Addiction Medicine

• Dental

• Other resident, please specify ________

GO TO Q29

28. Please tell us about yourself. (Check all that apply.)

MEDICAL AND NURSING STUDENTS

• Med 1

• Med 2

• Med 3

• Med 4

• Clerkship

• Preceptorship

• Nursing

• Dental

• Medical Assistant

ALLIED HEALTH STUDENTS

• Allied Health (e.g., OT/PT SLP/Social Work, Counseling, etc.)

OTHER STUDENT

• Pre-doctoral student

• Graduate Student

• Undergraduate Student

• Other, please specify _______

29. Are you (check one):

• Male

• Female

30. In which State(s) do you provide services or go to school? [INSERT DROP-DOWN MENU FOR STATES AND TERRITORIES]

 AL

 AK

 AZ

 AR

 CA

 CO

 CT

 DE

 DC

 FL

 FM

 GA

 GU

 HI

 ID

 IL

 IN

 IA

 KS

 KY

 LA

 ME

 MD

 MA

 MH

 MI

 MN

 MP

 MS

 MO

 MT

 NE

 NV

 NH

 NJ

 NM

 NY

 NC

 ND

 OH

 OK

 OR

 PA

 PR

 PW

 RI

 SC

 SD

 TN

 TX

 UT

 VT

 VI

 VA

 WA

 WV

 WI

 WY

 Not applicable

31. Are you Hispanic/Latino(a)?

• Yes

• No

32. How would you describe your race? (Check all that apply.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

33. Are you the parent/caregiver of a child with FAS/FASD?

• Yes

• No

34. The age group of the patients/clients that you see is: (Check all that apply.)

• newborn to < 1 month

• 1 month to < 9 years

• 9 years to < 18 years

• 18 years to < 65 years

• 65 years and above

• Not applicable

Thank you for completing this survey.

CDC estimates the average public reporting burden for this collection of information as 9 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS

D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

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