NOFAS Webinar 3 month Survey - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Three Month Follow-Up Webinar Questionnaire

Thank you for attending WEBINAR TITLE on DATE. This questionnaire will be used by NOFAS for evaluation purposes only. This survey is being conducted for the Centers for Disease Control and Prevention and will take approximately 2 minutes to complete. Your responses will be kept secure.

Please select the most appropriate answer for the following questions.

1. The webinar enhanced my knowledge of fetal alcohol spectrum disorders (FASDs)

Strongly Disagree__ Disagree__ Neutral__ Agree__ Strongly Agree__

2. The webinar enhanced my skills in preventing alcohol-exposed pregnancies (AEP).

Strongly Disagree__ Disagree__ Neutral__ Agree__ Strongly Agree___

Not Applicable__

3. The webinar increased my confidence in addressing alcohol use and/or FASD with my patients/clients.

Strongly Disagree__ Disagree__ Neutral__ Agree__ Strongly Agree__

Not Applicable__

4. Have you been able to incorporate any new knowledge gained from the webinar in your clinical practice?

Strongly Disagree__ Disagree__ Neutral__ Agree__ Strongly Agree__

Not Applicable___

If yes, what did you incorporate? ____________________________________________

5. Any additional comments

________________________________________________________________________________________________________________________________________________

Thank you for completing the survey and for your valuable feedback!

CDC estimates the average public reporting burden for this collection of information as 2 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).

National Organization on Fetal Alcohol Syndrome

www.nofas.org | 1-(800)-66-NOFAS | information@nofas.org