NOFAS Webinar Survey - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

National Organization on Fetal Alcohol Syndrome Webinar Survey

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. Provider Type: Family Medicine___ Ob/Gyn___ Pediatrics___ Nurse___ Social Worker___ Medical Assistant____Other_____

2. Are you a student? Yes___ No___ (If yes, skip question 3.)

3. Years in Practice: 0-5___ 6-10___ 11-15___ 16-20___ >20___

4. This webinar increased my knowledge of the harmful effects of alcohol on the developing fetus. (Circle one)

Strongly Disagree__   Disagree__  Neutral__   Agree__   Strongly Agree__

5. I plan to use the content in my practice.

Strongly Disagree__ Disagree__ Neutral__ Agree__ Strongly Agree__

Thank you for participating and sharing your experience with NOFAS!

 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