7 SBIRT Self Efficency

Attachment 12: SELF EFFICACY 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 1 minute 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 Self-Efficacy – administered at Baseline, Post-test, and Follow-up

To what extent do you agree with each of the following statements?

	Strongly disagree (-2)	Somewhat disagree (-1)	Neither agree nor disagree (0)	Somewhat agree (1)	Strongly agree (2)
I feel confident counseling my patients to quit smoking
I feel confident counseling my patients about their drinking
I feel confident counseling my patients about their abuse of prescription drugs
I feel confident counseling my patients about their illegal drugs use
Most patients try to change their lifestyles when I advise them to do so
Patients without symptoms will rarely try to change their behavior based on my advice