Foundations Online Follow-up - Word

Form Approved

OMB No. XXXX-XXXX

Exp. Date xx/xx/xxxx

First 2 letters of your mother’s maiden name ___ ___

Month of your birthday ___ ___

Last 2 digits of your social security number ___ ___

E3. Great Lakes FASD Regional Training Center

Foundations of FASD 6-month Follow-up

Please circle the BEST answer for each of the following:	Staff Use Only
The best public health message related to alcohol consumption by women of childbearing age is: Women who know they are pregnant should not consume alcohol. Women who are pregnant or could become pregnant should not consume alcohol. All sexually active women should not consume alcohol. Women of childbearing age should not consume alcohol. Alcohol use, in moderation, is safe for all women.	1 (I-C)
Scientific studies of the effects of alcohol on the fetus have shown that: a. Alcohol has no effect on the development of the fetus in the third trimester. b. Alcohol can only affect fetal development in the first trimester. c. A small to moderate amount of alcohol is safest during the second trimester. d. Of all the different types of alcohol, wine is the safest for a pregnant woman to consume. e. None of the above is correct.	6 (IV-C) (I)
Which of the following is NOT required to confirm a diagnosis of fetal alcohol syndrome (FAS)? Facial dysmorphia Growth retardation Central nervous system (CNS) abnormalities Documentation of prenatal alcohol exposure All of the above are required for a diagnosis of FAS	9 (V-C) (I)

2. In your current position, do you provide services to women of childbearing age?

 YES  NO

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

1

(over)

1

(over)

3. On a scale of 0 to 10 where 0 means, “Not confident in my skills” and 10 means “Totally confident in my skills,” how confident are you in your skills to do the following? (circle one number per row)

	NOT Confident in my skills										TOTALLY Confident in my skills
a. Screen women for risky or hazardous drinking	0	1	2	3	4	5	6	7	8	9	10
b. Educate pregnant women about the effects of alcohol on their babies	0	1	2	3	4	5	6	7	8	9	10
c. Conduct brief interventions for reducing alcohol consumption	0	1	2	3	4	5	6	7	8	9	10
d. Utilize resources to refer patients who need formal treatment for alcohol abuse	0	1	2	3	4	5	6	7	8	9	10

4. In your current position, do you provide services to individuals who may be at risk of an FASD?

 YES  NO

5. On a scale of 0 to 10 where 0 means, “Not confident in my skills” and 10 means “Totally confident in my skills,” how confident are you in your skills to do the following? (circle one number per row)

	NOT Confident in my skills										TOTALLY Confident in my skills
a. Identify persons with possible FAS or other prenatal alcohol-related disorders	0	1	2	3	4	5	6	7	8	9	10
b. Diagnose persons with possible FAS or other prenatal alcohol-related disorders	0	1	2	3	4	5	6	7	8	9	10
c. Utilize resources to refer patients for diagnosis and/or treatment services	0	1	2	3	4	5	6	7	8	9	10
d. Manage/coordinate the treatment of persons with FASDs	0	1	2	3	4	5	6	7	8	9	10

2

(continued)

6. Did you view the podcast that was sent to you recently as a link in an email prior to completing this survey evaluation?

 YES  NO

7. How did you use the information you received at the training 6 months ago?

THANK YOU!