Form Approved
OMB No. 0920-1129
Exp. Date 08/31/2019
Healthcare Professionals Survey (Nursing)
You are invited to take part in a survey for health professionals. The purpose of this survey is to understand the opinions and practices of health professionals around their patients’/clients’ alcohol use and on the prevention, identification, and treatment of fetal alcohol spectrum disorders. Your feedback is important as it will help assess the efficacy of trainings and identify the needs of health professionals to better address the services they provide to patients/clients around alcohol consumption and/or the effects of alcohol use during pregnancy.
This survey will take approximately 9 minutes to complete and your responses will be kept secure.
Your participation is voluntary; you may decline to answer any question and you have the right to stop the survey at any time. Any information you provide will be presented in aggregate in a report and no individual identifying information will be included. There will be no costs for participating, nor will you benefit from participating.
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.
Physiological problems experienced by a newborn.
The range of effects that can occur in an individual who was exposed prenatally to alcohol.
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 in neuroimaging and/or a history of seizures
Cognitive/developmental deficiencies 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
Risky drinking for non-pregnant women ages 21 and older is defined as more than _____ standard drinks in a day, or more than _____ standard drinks per week on average: (Check only one response.)
2, 6
3, 7
3, 8
4,
7
What advice would you give your patient/client about how much alcohol is safe to drink during pregnancy? (Check only one response.)
No more than one drink per day
No more than one or two drinks per week
Minimal alcohol is okay only during certain trimesters
There is no known safe amount of alcohol consumption during pregnancy
When is it safe to drink alcohol during pregnancy? (Check only one response.)
During the first three months
During the last three months
Once in a while
Never
Rate the importance of providing counseling to your patients/clients on risky alcohol use in women of childbearing age: (Check only one response.)
Not at all important
Somewhat important
Moderately important
Very important
Extremely important
If you are a student, please skip to Question 9. Otherwise, please continue.
When do you (or someone in your practice) ask your patients/clients or their parents/caregivers about their alcohol use? (Check only one response.)
Never
Annually
At each visit
When indicated (please describe: ____________________)
Other, please specify____________
My practice has a consistent process to screen or obtain information from all patients/clients about their alcohol use. (Check only one response.)
Yes
No
Don’t Know
Not applicable to the patients/clients in my practice setting
If yes, please continue. Otherwise, skip to Question 9.
What does initial patient/client screening for alcohol use consist of in your practice setting? (Check only one response.)
Informal questions (Do you drink? How often/much do you drink?, etc.).
Formal screening tool or evidence-based/ validated screening instrument (AUDIT, AUDIT-C, DAST, CAGE, CRAFFT, NIAAA Youth Alcohol Screen, etc.).
I don't know.
Who generally conducts the initial screening for alcohol? (Check all that apply.)
Nurse (including nurse practitioner)
Social worker
Behavioral health specialist (coach)
Psychologist
Physician
Physician’s Assistant
Medical Assistant
Other, please specify ____________________
Is screening for alcohol use followed by some type of intervention in your practice setting? (Check all that apply.)
No, there is no patient/client education or intervention done following the initial screening
Yes, all patients/clients are given educational materials/information on “safe” levels of alcohol and health risks associated with consuming too much alcohol
Yes, patients/clients who screen positive for risky alcohol use are asked follow-up questions and provided brief counseling.
Yes, patients/clients 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).
Not sure if there is an intervention following the initial screening.
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).
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Disagree |
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Strongly Agree |
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On a scale from 1 to 5 where 1 means you are not confident in your skills and 5 means you are totally confident in your skills, how confident are you in your skills to do the following? (Select one number per row).
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Slightly confident in my skills |
Moderately confident in my skills |
Very confident in my skills |
Totally confident in my skills |
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Are you aware of the CDC training website on FASD and risky alcohol use (www.cdc.gov/ncbddd/fasdtraining.html)?
YES NO
If yes, have you ever taken an FASD training on the CDC website?
Yes, within the last 12 months
Yes, more than 12 months ago
No, but I intend to within the next 12 months
No, and I don’t intend to within the next 12 months
Please describe your primary professional role:
Nurse or midwife, in clinical practice
Nurse or midwife, not in clinical practice
Nurse or midwife, retired
Student
Other, please specify: _________________________
If you are a nurse, please answer the below questions. Otherwise, please skip to demographics.
Are you a member of any of the following nursing organizations? (Check all that apply.)
American Nurses Association (ANA)
American College of Nurse Midwives (ACNM)
Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN)
Nurse Practitioners in Women’s Health (NPWH)
What is your current education level?
DNP
MSN
BSN
RN Diploma
DEMOGRAPHICS
What sex were you assigned at birth, on your original birth certificate?
Male
Female
Refused
I don’t know
Do you currently describe yourself as male, female, or transgender?
In which state(s) do you provide services or go to school?
q AL
q AK
q AZ
q AR
q CA
q CO
q CT
q DE
q DC
q FL
q FM
q GA
q GU
q HI
q ID
q IL
q IN
q IA
q KS
q KY
q LA
q ME
q MD
q MA
q MH
q MI
q MN
q MP
q MS
q MO
q MT
q NE
q NV
q NH
q NJ
q NM
q NY
q NC
q ND
q OH
q OK
q OR
q PA
q PR
q PW
q RI
q SC
q SD
q TN
q TX
q UT
q VT
q VI
q VA
q WA
q WV
q WI
q WY
q Not applicable
What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
How would you describe your race? (Check all that apply.)
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Thank you for completing this survey.
CDC estimates the average public reporting burden for this collection of information as 9 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 (0920-1129).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | FASD PIC AND NATIONAL PARTNER CROSS SITE EVALUATION |
Author | Rich Ann Baetz |
File Modified | 0000-00-00 |
File Created | 2021-02-14 |