Resident-Trainee Overall Program Evaluation

Resident/Trainee Program Evaluation

Form Approved

OMB No. xxxx-xxxx

Exp. Date: xx/xx/xxxx

Fetal Alcohol Spectrum Disorders

Improving Continuity of Care for Children and Families Affected by Prenatal Alcohol Exposure

The public reporting burden of this collection of information is estimated to average 15 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)

Preceptor First and Last Initials:

Clinic Name:

Clinic City and State:

On a scale of 1 to 5 (1 strongly disagree to 5 strongly agree) Please rate the extent to which the Improving Continuity of Care for Children and Families Affected by Prenatal Alcohol Exposure program achieved the stated learning objectives.

Learning Objective 1 Categorize the conditions within the continuum of FASDs and understand their prevalence.	1 | 2 | 3 | 4 | 5
Learning Objective 2 Recognize the neurodevelopmental phenotype associated with prenatal alcohol exposure.	1 | 2 | 3 | 4 | 5
Learning Objective 3 Identify presenting concerns and care coordination for individuals with FASDs in the pediatric medical home.	1 | 2 | 3 | 4 | 5
Learning Objective 4 Understand the importance of screening all patients for a history of prenatal alcohol exposure.	1 | 2 | 3 | 4 | 5
Learning Objective 5 Recognize the role that social attitudes and stigma have in early identification of FASDs.	1 | 2 | 3 | 4 | 5
Learning Objective 6 Relate the value of a diagnosis of an FASD.	1 | 2 | 3 | 4 | 5
Learning Objective 7 Apply a family centered care approach to providing care to children with an FASD and their families as part of the pediatric medical home.	1 | 2 | 3 | 4 | 5

Please share comments or suggestions related to how the learning objectives could better support your continued professional development with respect to screening, assessment and diagnosis of FASDs.

(open text box)

How would you rate this educational activity overall
☐ Poor
☐ Fair
☐ Good
☐ Very good
☐ Excellent

Based on your experience for this learning session, on a scale of 1 to 5 (1 strongly disagree) to 5 (strongly agree) rate your agreement with each of the following statements.

• I can use the information presented in my practice. 1 | 2 | 3 | 4 | 5

• The recorded session enhanced achievement of learning objectives. 1 | 2 | 3 | 4 | 5

• Clinical report(s) and article(s) enhanced achievement of learning objectives. 1 | 2 | 3 | 4 | 5

• Case example enhanced achievement of learning discussion. 1 | 2 | 3 | 4 | 5
  
  
  

Please indicate if you viewed the following video vignettes.

Video Vignette	Independently	As part of a meeting or group discussion	Not used
Session 1: Effects and prevalence of prenatal alcohol exposure	☐	☐	☐
Session 2: Common Presenting Concerns in Children with Prenatal Alcohol Exposure	☐	☐	☐
Watch Session 3: Overcoming Social Attitudes and Women with Substance Use Disorders	☐	☐	☐

Please indicate if you utilized the following enrichment activities for this learning session.

	Please indicate how you utilized this resource or activity (select all that apply)
Case Discussions	Independently	As part of a meeting or group discussion	Not used
Review case 1: 3-year-old male (screening for prenatal alcohol exposure)	☐	☐	☐
Review case 2: 8-year-old male (care coordination with school)	☐	☐	☐
Review case 3: 11-Year old male (anticipatory guidance for family)	☐	☐	☐
Review case 4: 13-year-old male (differential diagnosis)	☐	☐	☐

	Please indicate how you utilized this resource or activity (select all that apply)
Policy and Guidelines	Independently	As part of a meeting or group discussion	Not used
Review Clinical Reports “Fetal Alcohol Spectrum Disorders” and “The Role of Integrated Care in a Medical Home for Patients with a Fetal Alcohol Spectrum Disorder.”	☐	☐	☐
Review the differential diagnosis tables in the article “Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure.”	☐	☐	☐
Review Clinical Report: “Families Affected by Parental Substance Use “	☐	☐	☐
Review Screening for Prenatal Alcohol Exposure: An implementation guide for pediatric primary care providers.	☐	☐	☐

	Please how you utilized this resource or activity (select all that apply)
Clinic/Practice Application	Independently	As part of a meeting or group discussion	Not used
Review AAP.org FASD Toolkit Evidence based interventions specific to children with FASDs.	☐	☐	☐
Review protocol at your clinic for documenting birth history and prenatal exposures.	☐	☐	☐
Record self (and/or practice with a college) a mock interview with birth mother regarding birth history and prenatal exposures.	☐	☐	☐
Review and/or revise clinic referral network for community-based services for children that fit the neurodevelopmental phenotype for FASDs.	☐	☐	☐

Based on your experience for this program, rate your recommendation for using the enrichment resources and activity in a future iteration of this program. Rate your recommendation on a scale of 1 to 5 (1 strongly do not recommend) to 5 (strongly recommend) (0 not applicable, or activity/resource not used). Comment on how the enrichment activities supported or distracted from your learning/teaching experience and that of the residents/trainees.

Program Activities	Recommendation	Comments
Session 1: Effects and prevalence of prenatal alcohol exposure	0 | 1 | 2 | 3 | 4 | 5
Session 2: Common Presenting Concerns in Children with Prenatal Alcohol Exposure	0 | 1 | 2 | 3 | 4 | 5
Session 3: Overcoming Social Attitudes and Women with Substance Use Disorders	0 | 1 | 2 | 3 | 4 | 5
Case studies	0 | 1 | 2 | 3 | 4 | 5
Policy and guidelines	0 | 1 | 2 | 3 | 4 | 5
Clinic/Practice Application	0 | 1 | 2 | 3 | 4 | 5

GENERAL QUESTIONS
Responses to the following questions are required for all learners to ensure compliance with AAP, AMA and ACCME standards for AMA PRA Category 1 Credits™.

Based on what you learned in this activity, do you plan to change:

1. The strategies you implement in practice (e.g., how you diagnose/manage Yes | No
   patients, coordinate care, etc.)?

2. What you do in practice (e.g., how you perform exams, instruct, counsel Yes | No
   patients/families, etc.)?
   
   If YES to either of the above questions, please identify any changes in practice that you plan to make:
   (open text box)
   
   If NO and you do not plan to make changes in practice, other than lack of time and resources, why not? (select all that apply)
   ☐ Systems-related barriers - please describe: (open text box)
   ☐ The activity reinforced what I am already doing in practice
   ☐ No practice changes were recommended
   ☐ Changes were not appropriate options for my practice
   ☐ Other - please describe: (open text box)

On a scale of 1 to 7, what was the return on your investment of time/effort for 1 | 2 | 3 | 4 | 5 | 6 | 7
participating in this activity? (1 low return to 7 high return)

Do you feel a commercial product, device, or service was inappropriately promoted Yes | No
in the educational content?

If yes, please comment: (open text box)

On a scale of 1 to 5 (1 not at all valuable to 5 highly valuable), please rate the value 1 | 2 | 3 | 4 | 5
of the inclusion of MOC points for participating in this activity.

This MOC activity is relevant to my current practice. Yes | No

If yes, please explain why: (open text box)

Please share any additional comments and suggestions for how to improve this educational session.

(open text box)

Thank you for participating in this session and for completing this evaluation!

Submit to:

Josh Benke, FASD Program Manager,
American Academy of Pediatrics, Division of Children with Special Needs
V: 630/626-6081 | F: 847/434-8000 | E: jbenke@aap.org