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Q21
Form Approve
OMB No. 0920-XXX
Exp. Date XX/XX/20X
Dear Colleagues,
Please consider completing an electronic survey being conducted as part of an AAP grant
funded project focused on the prevention, early identification, and care for children who have
or may have one of the fetal alcohol spectrum disorders (FASDs).
Purpose: The intent of this survey is to gather information about pediatric primary care and
sub-specialty care attitudes and practices regarding the identification of children who have o
may have one of the FASDs as well as corresponding care management, care coordination,
and care planning for children who were prenatally exposed to alcohol.
Eligible Participants: All pediatricians and pediatric sub-specialists are welcome to
complete the survey. Questions will be most applicable to primary care and sub-specialty
pediatricians who provide well-child care in an out-patient or ambulatory care setting.
Time: The survey will take approximately 5-10 minutes to complete.
All surveys will be anonymous. Survey results will be used to inform the development of
education, awareness and practice-based resources for pediatricians and other pediatric
clinicians. Please contact the AAP Program Manager, Josh Benke, at 847/434-7863 or
jbenke@aap.org if you have questions about the survey and/or its results.
Thank you in advance for the time you take to complete this survey.
Best regards,
Vincent C Smith, MD, FAAP
Medical Director
AAP FASD Prevention, Early Identification and Management Program
Public reporting burden of this collection of information varies from 5-10 minutes with an estimated average of 7
minutes per response, including the time for reviewing instructions, searching existing data/information sources,
gathering and maintaining the data/information needed, and competing 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).
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Q1
Do you currently provide primary or specialty medical care to pediatric patients?
Yes
No
Are you currently in a pediatric residency or fellowship training program?
Yes
No
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Q2
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Q3
Do you feel it is important to inquire about prenatal alcohol exposure in your patient population?
Yes
No
Q4
Please check which of the following two statements below best corresponds with your personal viewpoint. Please check
only ONE box.
Occasional consumption of alcohol (one standard drink per day or less) 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.
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Q5
Please indicate to what extent you agree with the following statements:
Alcohol consumption during pregnancy:
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
a. is more prevalent in women with
lower incomes
b. is more prevalent in women with
higher incomes
c. does not vary between income
levels
d. is more prevalent in women with
lower levels of education
e. is more prevalent in women with
higher levels of education
f. does not vary between education
levels
g. is more prevalent in AfricanAmerican women
h. is more prevalent in AmericanIndian women
i. is more prevalent in Anglo-white
women
j. is more prevalent in AsianAmerican women
k. is more prevalent in
Hispanic/Latina-American women
l. does not vary between ethnic or
racial groups
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Q6
To what extent do you agree that fetal alcohol syndrome (FAS) is more likely to occur in children from certain racial or ethni
groups?
Strongly Disagree
Disagree
Neither Agree nor
Disagree
Agree
Strongly Agree
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Q7
To what extent do you agree that making a diagnosis of fetal alcohol syndrome (FAS) stigmatizes the child and/or the
family?
Strongly Disagree
Neither Agree nor
Disagree
Disagree
Agree
Strongly Agree
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Q8
To what extent do you agree that concerns regarding stigma contribute to pediatricians' reluctance to identify the
constellation of physical and behavioral health concerns that could lead to a diagnosis of one of the fetal alcohol spectrum
disorders FASDs) in their patient?
Strongly Disagree
Neither Agree nor
Disagree
Disagree
Agree
Strongly Agree
Q9
Which of the following are the primary dysmorphic facial features associated with prenatal alcohol exposure? (Check all tha
apply)
Wide inner canthal distance
Short palpebral fissures
Full lips
Smooth philtrum
Thin upper lip
Flaring nares
Don't know/unsure
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Q10
Which of the following could indicate that a child may have been exposed to alcohol prenatally? (Check all that apply)
Growth deficiencies
Clinically significant abnormalities on neuroimaging and/or a history of seizures
Cognitive/developmental deficits or discrepancies
Executive function deficits
Delays in gross/fine motor function
Problems with self-regulation/self-soothing
Delayed adaptive skills
Confirmed history of alcohol exposure in utero
Don't know/unsure
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Q11
The diagnosis of "neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)" as identified in the
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5):
a. Requires recognition of neurocognitive impairment, impaired self-regulation, and deficits in adaptive
functioning
b. Can be diagnosed without knowledge of confirmed prenatal alcohol exposure
c. Includes recognition of the 3 primary morphologic features of prenatal alcohol exposure
d. Is the least common manifestation of prenatal alcohol exposure
e. All of the above
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Q12
During the past two years, did you diagnose any children with fetal alcohol syndrome (FAS) or any of the fetal alcohol
spectrum disorders (FASDs)?
Yes
No
Q13
If Yes, which diagnostic schema (if any) did you use to support your diagnosis:
Institute of Medicine criteria
American Academy of Pediatrics algorithm and/or toolkit
Seattle 4-digit diagnostic criteria
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Other schema (please specify)
I did not use any particular schema
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Q14
During the past two years, did you refer any children for assessment for one of the fetal alcohol spectrum disorders?
Yes
No
Q15
In the past two years, have you participated in any training on fetal alcohol spectrum disorders (e.g., residency training,
CME training)?
Yes
No
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Q16
In the past two years, have you used, referenced or been made aware of the following fetal alcohol spectrum disorders
(FASDs) resources?
American Academy of Pediatrics FASD Online Toolkit
Centers for Disease Control and Prevention FASD Webpage
FASD Center for Excellence SAMHSA Webpage
NOFAS Website
Other reference or resource (please specify)
I did not use any particular FASD resources in the past two years
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Q17
How prepared are you to identify children who have or may have one of the Fetal Alcohol Spectrum Disorders?
Not at all prepared
A little Prepared
Moderately Prepared
Prepared
Completely prepared
Q18
How willing are you to diagnose and/or refer for further evaluation and possible diagnosis children who may have one of the
Fetal Alcohol Spectrum Disorders?
Not at all Willing
A little Willing
Moderately Willing
Willing
Completely willing
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Q19
Are you aware of clinical guidance on interviewing a birth mother for alcohol use in the three months before she knew she
was pregnant and/or while pregnant?
Yes (please specify)
No
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Q22
During a typical workweek, how many hours do you spend in the following professional activities? If you do not spend any
time in a particular activity, please enter zero (0) hours in the appropriate box.
Direct patient care
Administration
Academic medicine
Research
Fellowship training
Other (Specify)
Number of hours in Other activity above
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Q23
Are you currently in a pediatric residency training program?
Yes
No
Q24
Approximately what percentage of your time is spent in the following areas? Please make sure both percentage numbers
provided add to 100%.
General Pediatrics (Specify percentage of time spent in general pediatrics in the box below)
Other specialty/sub-specialty area (Specify the specialty area--i.e., developmental pediatrics--in the box
below)
Percentage of time in "Other specialty/sub-specialty area" (Specify percentage of time spent in specialty area
in the box below)
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Q25
Please indicate your primary employment site setting, that is, the setting where you spend most of your time. Please
indicate only ONE response.
Self-employed solo practice
Two physician practice
Pediatric group practice, 3-10 pediatricians
Pediatric group practice, >10 pediatricians
Multispecialty group practice
Health maintenance organization (staff model)
Medical school or parent university
Non-profit community health center
Non-government hospital or clinic
City/county/state government hospital or clinic
US government hospital or clinic
Other: (Specify)
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Q26
Please describe the community in which your primary practice/position is located?
Urban, inner city
Urban, not inner city
Suburban
Rural
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Q27
In what year were you born?
Q28
How many years have you been in practice (do not include formal training)?
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Q29
What is your gender?
Male
Female
Transgender
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Q30
With what racial or cultural group(s) do you identify yourself? Indicate all that apply.
White, non-Hispanic/Latin@
Hispanic/Latin@
Black/African American, non-Hispanic/Latin@
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaska Native
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Q31
Thank you for taking the time to complete this survey!
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| File Type | application/pdf |
| File Title | https://uwmadison.co1.qualtrics.com/CP/?ClientAction=EditSurvey |
| Author | GXW827 |
| File Modified | 2016-02-19 |
| File Created | 2016-02-10 |