SBI 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 ___ ___

E6. Great Lakes FASD Regional Training Center

Screening and Brief Intervention 6-month Follow-up Evaluation

Please circle the BEST answer for each of the following:	Staff Use Only
An episode of binge or risky drinking for women of childbearing age (18-44) is defined as more than ___ standard drinks in about a two hour period. a. 2 b. 3 c. 4 d. 5 e. 6	2 (II-C)
Which one of these is NOT considered a standard drink? 12 ounces of beer 12 ounces of wine cooler 5 ounces of wine 3 ounces of vodka All of the above are standard drinks	3 (II-C)
Positive responses given to items on the TWEAK or the T-ACE screening instruments indicate: A diagnosis of alcoholism The likelihood that the woman will seek treatment for alcohol abuse The need for the health care provider to discuss the risks associated with drinking alcohol, especially when the woman is pregnant The difference between binge drinking and problem drinking The need for immediate admission to a treatment facility for further evaluation	4 (II-C)
Which of these is NOT part of the addictive disease process? a. Craving and compulsion b. Violent behavior c. Loss of control d. Continued use despite adverse consequences e. All of the above are part of the addictive disease process	5 (III-C)

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(over)

The public reporting burden of this collection of information is estimated to average 8 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)

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

 YES  NO

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

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(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!