Medical Assistants Follow-up Survey

Medical Assistants Follow-up Survey

Form Approved
OMB No. XXXX-XXXX
Exp. Date xx/xx/xxxx

The course you are taking will contain presentation materials developed by the Mountain Plains Practice and Implementation Center
(PIC), located at the University of Nevada, Reno. These materials are based on content developed by the Centers for Disease Control
and Prevention (CDC).
This survey does not ask you for any personal identifying information and the results will only be used to assist us in determining the
effectiveness of the course. The course instructor will not be able to view your individual responses or know if you completed this
survey. Likewise, you are not required to complete this survey and your participation in this class will not be affected regardless of your
decision.
Thank you for your time and enjoy the class.

1. Please enter the personal ID code you created for the pretest survey.
First letter of your mother's first name

First digit of your social security number

Last digit of your social security number

First letter of your mother's maiden name

______________________________________________________________________________
The public reporting burden of this collection of information is estimated to average 10 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)

Medical Assistants Follow-up Survey

The following items will be used only to describe the demographic makeup of the class.

2. Are you (choose one)
Male
Female

3. Are you Hispanic or Latino/a?
No
Yes

4. How do you describe your race? (check all that apply)
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White

5. In which state do you work?

6. In what type of medical setting do you work?
OB/GYN
Family medicine
Other (please specify)

Medical Assistants Follow-up Survey

The scenarios describe the alcohol use-related behaviors of two women. Please read each scenario
carefully and respond to the questions that follow.
7. Scenario 1
Over the past few months, Sally has started to drink more than her usual amount of alcohol. In fact, she
has noticed that she now needs to drink twice as much in order to get the same effect. Several times she
has tried to cut down or stop drinking. However, each time she tried she became very agitated and couldn’t
sleep, so would start drinking and the symptoms would go away. Her family has complained that she is
often hung over, moody, and has become unreliable – making plans one day and cancelling them the next.
In fact, they report that she frequently calls them while intoxicated and has no memory of the calls or what
she promised the next day.
In your opinion, how likely is it that Sally’s situation might be caused by…
Not at all likely
her own bad character.
a chemical imbalance in
her brain.
the way she was raised.
stressful circumstances
in her life.
a genetic or inherited
problem.

Not very likely

Neither likely nor
unlikely

Somewhat likely

Very likely

8. On a scale of 1 (Not at all) - 6 (Extremely), how likely would you be to…
Not at all likely
feel ashamed if people
knew someone like Sally
was a member of your
family?
be uncomfortable having
a conversation with
Sally?
be angry with Sally?
believe that Sally’s
drinking is controllable?
talk with Sally about her
drinking?
feel sorry for Sally?
think that Sally’s drinking
is her own fault?
interview Sally for a job if
you were an employer?
feel irritated with Sally?
be likely to help Sally?
feel sympathy for Sally?
believe that Sally is
responsible for her
drinking?
rent Sally an apartment if
you were a landlord?
be concerned about
Sally?
try to stay away from
Sally?

2

3

4

5

Extremely likely

Medical Assistants Follow-up Survey

9. Scenario 2
During the past year, Jessica has started to drink more than her usual amount of alcohol. In fact, she has
noticed that she now needs to drink twice as much in order to get the same effect. Three months ago,
Jessica found out that she is pregnant and her doctor told her she should not drink alcohol during her
pregnancy. Jessica has tried but so far has not been able to stop drinking. Some of Jessica’s friends told
her that when they were pregnant the taste and/or smell of alcohol made them sick. Jessica was hoping
that she would have the same reaction, but that has not been the case. Out of concern for Jessica’s health
and the health of her baby, her family has tried several times to talk with her about it. However, they are
telling her that she is being selfish and not behaving in the best interest of her child. This approach is only
increasing how guilty and ashamed Jessica is feeling about not being able to stop. As a result, Jessica has
become very secretive about her drinking, sneaking a drink whenever she has a chance.
In your opinion, how likely is it that Jessica ’s situation might be caused by…
Not at all likely
her own bad character.
a chemical imbalance in
her brain.
the way she was raised.
stressful circumstances
in her life.
a genetic or inherited
problem.

Not very likely

Neither likely nor
unlikely

Somewhat likely

Very likely

10. On a scale of 1 (Not at all) - 6 (Extremely), how likely would you be to…
Not at all likely
feel ashamed if people
knew someone like
Jessica was a member
of your family?
be uncomfortable having
a conversation with
Jessica?
be angry with Jessica?
believe that Jessica’s
drinking is controllable?
talk with Jessica about
her drinking?
feel sorry for Jessica?
think that Jessica’s
drinking is her own fault?
interview Jessica for a
job if you were an
employer?
feel irritated with
Jessica?
be likely to help Jessica?
feel sympathy for
Jessica?
believe that Jessica is
responsible for her
drinking?
rent Jessica an
apartment if you were a
landlord?
be concerned about
Jessica?
try to stay away from
Jessica?

2

3

4

5

Extremely likely

Medical Assistants Follow-up Survey

The following items deal with factors related to fetal alcohol spectrum disorders.
11. Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term describing the range of effects that can
occur in an individual whose mother drank alcohol during pregnancy.
True
False

12. FASD is preventable if a woman does not drink during her pregnancy.
True
False

13. The effects for FASD are always visible.
True
False

14. When is it safe to drink alcohol during pregnancy?
During the first three months
During the last three months
Once in a while
Never

Medical Assistants Follow-up Survey

15. How much alcohol is safe to drink during pregnancy?
One glass of wine
Two light beers
One shot of hard alcohol
None of the above

16. Screening for excessive alcohol use during pregnancy can be an effective strategy in reducing FASD.
True
False

17. How often do you talk to your patients or their parents/caregivers about prevention of excessive alcohol
use?
Never
Occasionally
About Half the Time
Frequently
Always

18. The practice in which I work has a protocol to screen all patients about their alcohol use.
Yes
No
Don't know
Not applicable to the patients in my practice setting.

Medical Assistants Follow-up Survey

19. What does initial patient SCREENING for alcohol use consist of in your practice?
Informal questions (Do you drink? How often/much do you drink?, etc.)
Formal screening tool or evidence-based screening instruments (AUDIT, AUDIT-C, DAST, CAGE, etc.)
I don't know.

20. Who generally conducts the initial SCREEN for alcohol? (Check all that apply.)
Nurse (including nurse practitioner)
Social worker
Behavioral health specialist (coach)
Psychologist
Physician
Medical Assistant
Other (please specify)

21. Is screening for alcohol use followed by some type of intervention in your practice? (Check all that
apply.)
No, there is no patient education or intervention done following the initial screening.
Yes, all patients are given educational materials/information on “safe” levels of alcohol and health risks associated with
consuming too much alcohol.
Yes, patients who screen positive for risky alcohol use are asked follow-up questions and provided brief counseling.
Yes, patients who screen positive for risky alcohol use are asked follow-up questions and provided with additional resources (e.g.,
a list of treatment and/or counseling services in the community).

Medical Assistants Follow-up Survey

22. Who generally does the intervention in your practice? (Check all that apply.)
No one intervenes, to my knowledge
Physician
Physician’s Assistant
Psychologist
Social worker
Behavior health specialist (coach)
Nurse (including nurse practitioner)
Other (please specify)

23. Does your practice bill for screening and brief intervention services?
Yes
No
Not sure

Medical Assistants Follow-up Survey

24. On a scale of 0-10 with 0 meaning “Completely Disagree” and 10 meaning “Completely Agree” to what
extent do you agree with the following statements.
0
(Completely
disagree)

1

2

3

4

5

6

7

8

9

10
(Completely
agree)

Alcohol consumption
during pregnancy is
more prevalent in
women with lower
incomes.
Alcohol consumption
during pregnancy is
more prevalent in
women with lower
levels of education.
Alcohol consumption
during pregnancy is
more prevalent in
Anglo-white women.

25. Which of the following two statements best corresponds with your personal viewpoint (please check
only ONE box).
Occasional consumption of one standard drink alcoholic drink per day or less (i.e., 1.5 oz. hard liquor, 12 oz. of beer or 5 oz. of
wine) during pregnancy is not harmful to the mother or the fetus.
Pregnant women or women who are trying to become pregnant should completely abstain from consuming alcohol.

Medical Assistants Follow-up Survey

26. On a scale from 0 to 4 where 0 means you completely disagree with the statement and 4 means you
completely agree, to what extent do you disagree or agree with the following statements.
Completely
disagree
It is important to
routinely screen all
patients for alcohol use
It is important to screen
all pregnant women for
alcohol use
It is important to screen
all women of
childbearing age, for
alcohol use
I am comfortable asking
women of childbearing
age, including pregnant
women, about their
alcohol use
I am comfortable having
a conversation with
patients who indicate
risky alcohol use.
Screening for alcohol
use confers a negative
stigma to the woman
being screened.

Disagree

Neither agree nor
disagree

Agree

Completely agree

27. On a scale from 0 to 10 where 0 means “Not confident in my skills” and 10 means “Totally confident in
my skills,” how confident are you in your skills to do the following?
0
(Completely
disagree)
Inquire about potential
prenatal exposure for
pediatric patients
Screen women for risky
or hazardous drinking
Educate women of
childbearing age,
including those who are
pregnant about the
effects of alcohol on a
developing baby
Conduct brief
interventions for
reducing alcohol use
Utilize resources to
refer patients who need
formal treatment for
alcohol abuse

1

2

3

4

5

6

7

8

9

10
(Completely
agree)

Medical Assistants Follow-up Survey

28. To what extent to you agree with the following statements?
Strongly disagree
This training increased
my understanding of the
effects of prenatal
alcohol exposure on the
developing fetus.
I have applied the
concepts presented in
this training.
I have recommended
this presentation to
others.
Overall, I am satisfied
with the quality of this
training.

Thanks for your participation!!!

Disagree

Neither agree nor
disagree

Agree

Strongly agree