CBIT Program 3-month Follow-up

CBIT Program 3 Month Follow-up

Form Approved, OMB No. 0920-XXXX Exp. Date XX/XX/20XX
This survey is in reference to the CBIT training program you attended on XX. The program was hosted through a
partnership with the US Centers for Disease Control and Prevention. We would like to assess the impact of the program
on your patient care and survey results will enable us to better focus our outreach efforts.
Public reporting burden of this collection of information is estimated to average  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. 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).

1. Please indicate your profession.
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Physician

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Nurse Practitioner

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Social Worker

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Physician Assistant

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Ph.D.

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Counselor

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Nurse

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Psychologist

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Occupational Therapist

Other:

2. Since the CBIT workshop:
0

1-5

6-10

>10

N/A

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n

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n

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How many of these patients have you treated with CBIT?

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For how many of these patients was CBIT an effective management

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n

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n

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How many patients with tic disorders/Tourette syndrome have you
evaluated?

strategy?
Comment

3. How have you integrated the information you learned into your patient care?
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I now implement CBIT with my patients

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I now educate my patients about CBIT

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I now refer patients to CBIT practitioners

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I have not integrated the information into my care

Other Changes (please specify)

CBIT Program 3 Month Follow-up
4. Do you think that your skills in managing patients who have TS have improved as a
result of attending the CBIT program?
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Yes

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No

Comment:

5. Whether or not you have made a change, please rate the usefulness of this program
to your current practice.
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Very useful

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Useful

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Somewhat useful

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Not at all useful

Comment