3 Clincal Practices Assessment

Attachment 8: CLINICAL PRACTICES QUESTIONAIRE

Web-based Skills Training for SBIRT (Screening Brief Intervention and Referral to Treatment)

August 2011

OMB # 0925-XXX

Expiration Date xx/xxxx

Public reporting burden for this collection of information is estimated to average less than 5 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. Each time the assessment is completed, it is expected to be completed in a single sitting. 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*).  Do not return the completed form to this address.

SBIRT Clinical Practices Questionnaire – administered at Pretest and Follow-up (see below for Clinical Practice Intentions to be administered at Post-test)

1. During the past 3 months, with an adult patient during a periodic health maintenance visit or routine check-up, how often did you do the following?

pract1	Never 0% (0)	Rarely 1-20% (1)	Some- times 21-40% (2)	Half time 41-60% (3)	Often 61-80% (4)	Usually 81-99% (5)	Always 100% (6)
Screen for alcohol abuse or dependence
Screen for misuse of prescriptions drugs
Screen for illicit substance use
Screen for tobacco use
Use a standard validated measure to screen for alcohol, tobacco, or other drugs
Give patients feedback about screening results
Ask patients their thoughts about your feedback

2. During the past 3 months, when you saw a patient who was drinking heavily, abusing prescription drugs or using illicit substances, how often did you:

pract2	N/A (-9)	Never 0% (0)	Rarely 1-20% (1)	Some- times 21-40% (2)	Half time 41-60% (3)	Often 61-80% (4)	Usually 81-99% (5)	Always 100% (6)
Describe the harms associated with continued substance use?
Give clear advice to quit or cut back?
Discuss ways for patients to change their substance use?
Refer those needing specialized treatment?
Follow-up with patients about their substance use at their next clinic visit?

3. During the past 3 months, when you saw a patient who was a smoker or tobacco user, how often did you:

pract3	N/A (-9)	Never 0% (0)	Rarely 1-20% (1)	Some- times 21-40% (2)	Half time 41-60% (3)	Often 61-80% (4)	Usually 81-99% (5)	Always 100% (6)
Advise them to quit?
Assess their willingness to quit?
Provide materials about tobacco use and quitting?
Prescribe FDA approved medications for smoking cessation, if appropriate?
Refer them to a quitline or other form of support?
Follow-up with patients about their tobacco use at their next clinic visit?