DSW Report - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

DSW Report

Objective	To obtain periodic feedback on your assessment of the DSW team(s) you participate in for CDC’s FASD PIC and National Partner project
Who is to complete this report?	Everyone participating in the CDC project except NOFAS staff. If you participate in more than one DSW, complete this report for each DSW in which you participate.
How often is this report to be completed?	Once every six months
When is the completed report due?	April 15, 2016, 2017, 2018 October 15, 2016, 2017, 2018

As you are completing this assessment, please bear in mind the purpose of the program and its key concepts.

Purpose of the Program

This program funds PICs and national partners who will work collaboratively over the four year funding cycle to achieve practice and systems-level change in FASD prevention, identification, and treatment through health provider training and the promotion and implementation of evidence-based interventions. Underlying the program are several key strategies:

• Sharing Expertise: PICs contribute expertise in FASDs and in the delivery of state-of-the-art training while the national partners provide expertise in representing their members’ practice perspectives and values. Using a collaborative approach of pairing each PIC grantee with a national partner, the intent is that training, messaging tailored to specific target audiences, and promotion and implementation of evidence-based interventions will result in greater interest, understanding and adoption of practice change.

• Increasing Reach to Targeted Groups: The PICs collaboration with their national partners is designed to increase reach to the target audience and sustainable practice change through promotion and implementation of evidence-based interventions.

• Fostering Practice Change: This work is intended to foster practice change in the defined target audience and ultimately result in sustainable change at both the practice and systems level. There is an overall emphasis in this initiative on strengthening strategic partnerships with key national medical societies, professional organizations, and constituent groups.

• Increasing Emphasis on Primary Prevention: In addition to emphasizing primary prevention, this work focuses strongly on training, promotion and implementation of evidence-based interventions, and sustained practice change among health care professionals. Through the combined efforts of PICs and national partners, the program outcome will result in overall improved and sustained practice change.

1. Click on the box to select the DSW you are assessing with this form. (Check one; fill out additional forms if needed if you participate in multiple DSWs).

☐Family Physicians

☐Medical Assistants

☐Nursing

☐Obstetrics/Gynecology

☐Pediatrics

☐Social Work

2. Based on the DSW you selected in question #1, please tell us whether you strongly disagree, disagree, agree, or strongly agree to the following statements.

	Strongly Disagree 0	Disagree 1	Agree 2	Strongly Agree 3
The DSW members have a good understanding of their respective responsibilities.	○	○	○	○
DSW members are usually willing to take into account schedules of individuals when planning their work.	○	○	○	○
Individuals on the DSW share similar ideas about how to accomplish project objectives.	○	○	○	○
DSW members are willing to discuss individuals’ issues.	○	○	○	○
DSW members cooperate with the way project plans are organized.	○	○	○	○
DSW members cooperate with new, agreed upon project plans.	○	○	○	○
Individuals are asked for their opinions.	○	○	○	○
DSW members anticipate when they will need others’ help.	○	○	○	○
Important information is usually passed between and among DSW members.	○	○	○	○
Disagreements within the DSW sometimes remain unresolved.	○	○	○	○

3. Please give examples of what worked well for collaboration efforts in the last six months? (If applicable, consider commenting on concepts defined on p. 1: Sharing Expertise; Increasing Reach to Target Group; Fostering Practice Change; and Increasing Emphasis on Primary Prevention.) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. What collaboration efforts within your DSW did not work well in the last six months? Please give examples. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CDC estimates the average public reporting burden for this collection of information as 60 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).