AAP 3 Month Follow-up Survey

Form Approved

OMB No. 0920-XXXX

Exp.: XX/XX/20XX

AMERICAN ACADEMY OF PEDIATRICS

3-MONTH FOLLOW-UP EVALUATION SURVEY

Thank you completing the training on fetal alcohol spectrum disorders (FASD) a few months. We would like to invite you to complete a post-training evaluation survey. We appreciate your willingness to help us evaluate the effectiveness of the training and its impact on your practice as you address the prevention, identification, and treatment of FASD.

This survey will take approximately 2 minutes to complete. Your responses will be kept secure and no individually 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 AAP.

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.

Please submit questions to the project partners at PEHDIC@aap.org.

UNIQUE IDENTIFIER INFORMATION

1. First 2 letters of your mother’s maiden name ___ ___

2. Month of your birthday ___ ___

3. Last 2 digits of your social security number ___ ___

4. State in which you practice ___ ___

The public reporting burden of this collection of information is estimated to average 2 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)

PRACTICE QUESTIONS

5. How often do you do the following? (Mark one response per row)

	Never	Rarely	Sometimes	Usually	Always
Inquire routinely about prenatal exposure to alcohol	1	2	3	4	5
Identify patient as someone who may have one of the FASDs	1	2	3	4	5
Diagnose patient as someone who may have one of the FASDs	1	2	3	4	5
Refer patient for diagnosis and/or treatment services	1	2	3	4	5
Manage/coordinate the treatment of patient	1	2	3	4	5

6. During the past three months, did you diagnose any children with fetal alcohol syndrome (FAS) or one of the fetal alcohol spectrum disorders (FASDs)?
   ☐ Yes ☐ No
   
   If YES, please specify which diagnostic schema (if any) you used to support your diagnosis:
   ☐ Institute of Medicine criteria
   ☐ American Academy of Pediatrics algorithm and/or toolkit
   ☐ Seattle 4-Digit Diagnostic Code (University of Washington)
   ☐ Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
   ☐ Other schema (please specify) _____________________________
   ☐ I did not use any particular schema

7. During the past three months, did you refer any children for FASD assessment?
   ☐ Yes ☐ No
   
   

8. As a result of participating in the FASD learning activity, did you intend to make a change in your practice?
   ☐ Yes ☐ No

If yes, please describe what you did differently in practice over the past 3 months:

9. Did you encounter any barriers to making a change in your practice?

☐ Yes ☐ No

If yes, please describe:

Thank you for taking the time to complete this survey!

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