FASD Prevention, Identificaiton, & Alcohol Screening Post-Testing Evaluation

Form Approved

OMB No, 0920-1129

Exp. Date 08/31/2019

FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation

Thank you for completing this survey. You are helping us to improve and identify the needs of healthcare providers in preventing and identifying fetal alcohol spectrum disorders. This survey is being conducted for the Centers for Disease Control and Prevention and will take approximately 3 minutes to complete. Your responses will be kept secure.

1. 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.

2. The effects for FASDs are always visible.

• True

• False

3. 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

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

• Short palpebral fissures

• Full lips

• Smooth philtrum

• Thin upper lip

• Flat nose

• Don’t know/unsure

5. 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 patients	1	2	3	4	5

7. On a scale from 1 to 5 where 1 means “Not at all confident in my skills” and 5 means “Totally confident in my 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	Not Applicable
a. Asking women, including pregnant women, about their alcohol use	1	2	3	4	5
b. Having a conversation with patients/clients who indicate risky alcohol use	1	2	3	4	5
c. Educating women of childbearing age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
d. Conducting brief interventions for reducing alcohol use	1	2	3	4	5
e. Utilizing resources to refer patients/clients who need formal treatment for alcohol abuse	1	2	3	4	5
f. Inquiring about potential prenatal alcohol exposure for my patients/clients	1	2	3	4	5
i. Referring patients/clients for diagnosis and/or treatment services for an alcohol use disorder	1	2	3	4	5

7. How will you use the information you received today?

__________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11. 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. Has your practice experienced any of the following barriers to effective implementation of alcohol screening and brief intervention? (Check all that apply).

 No barriers; we screen and intervene consistently and well

 Time limitations during patient/client visits

 It is not required; lack of incentive

 Attitudes of providers and/or staff about substance use/abuse

 Workforce needs education and training on screening and brief intervention

 Not easily accessible in the Electronic Health Record

 Concerns about damaging rapport with patients/clients

 Patient reluctance to be honest about alcohol use, or resistance to treatment

 Concerns about confidentiality and reporting requirements (example: to social services agency)

 Inadequate referral sources and/or system for making referrals

 Billing for alcohol screening, assessment, and counseling/intervention is not in place

 Patient/client inability to pay for treatment

 Other (please specify) _______________________________________________

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

 CDC estimates the average public reporting burden for this collection of information as 5 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, MSD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1129).