Great Lakes Comprehensive 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 ___ ___

E11. Great Lakes FASD Regional Training Center

FASD Comprehensive Post-Training Evaluation

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)
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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The public reporting burden of this collection of information is estimated to average 20 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)

Please circle the BEST answer for each of the following:	Staff Use Only
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)
Although specific deficits experienced by individuals with an FASD vary widely, behavioral deficits are likely to include which of the following: Memory problems, underactivity, and self-injurious behavior Inattention, memory problems, and hyperactivity Particular mannerisms, hoarding, and memory problems Emotion regulation, weight loss, fatigue, irritability Auditory hallucinations, disorganized speech, and flat affect	7 (V-C)
Which of the following include all three facial abnormalities associated with fetal alcohol syndrome? Low set ears, large palpebral fissures, large forehead Small palpebral fissures, smooth philtrum, thin upper lip Large palpebral fissures, smooth philtrum, thin upper lip Large forehead, flattened cheeks, small palpebral fissures Thin upper lip, distinct philtrum, ectropion	8 (V-C)
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)
A variety of strategies have been found to be effective when working with individuals with an FASD. Which one of the following may not be as effective? Concise, explicit instructions Stable routines Social cues Visual aids Repetition	10 (VI-C)
Which one of the following statements is NOT correct? Some women expose their fetus to alcohol because of alcohol dependence or addiction. Health providers seek the best outcomes for women and fetuses by efforts to increase foreseeable benefits and minimize foreseeable harms. Most medical societies advocate coercive methods as a first intervention for women who expose a fetus to alcohol. Health providers have an ethical duty to respect their patients. Under certain circumstances health providers cannot guarantee confidentiality.	11 (VII-C)

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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

	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

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)

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6. How will you use the information you received during the training today?

7. What additional information do you need to make changes in your practice?

8. What additional comments do you have about this training?

9. We would like to know your thoughts about this training/presentation. Please circle the number that most clearly represents the extent to which you agree with each of the following statements.

To what extent to you agree with the following statements?	Strongly disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly agree
The training content will be useful to me professionally.	1	2	3	4	5
The training content increased my awareness & knowledge of the harmful effects of alcohol on the developing fetus.	1	2	3	4	5
This training had a positive impact on my level of comfort in discussing issues related to FASDs with my patients/clients.	1	2	3	4	5
The presentation content was culturally relevant.	1	2	3	4	5
The speaker(s) provided the information in a culturally competent/sensitive manner.	1	2	3	4	5
I am satisfied with my experience in this training.	1	2	3	4	5
The instructor seemed knowledgeable about the topics.
TRAINER 1 (NAME)	1	2	3	4	5
TRAINER 2 (NAME)	1	2	3	4	5
TRAINER 3 (NAME)	1	2	3	4	5
TRAINER 4 (NAME)	1	2	3	4	5

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Please take a moment to tell us about yourself:
Are you (Circle one): 1=Male 2=Female 3=Transgender In which State do you provide services? 1=Wisconsin 2=Michigan 3=Indiana 4=Ohio 5=North Carolina 6=Minnesota 7=Hawaii 8=Other Specify ______________________ (8a) Are you Hispanic or Latino(a)? 1=Yes 2=No How would you describe your race? (Select all that apply) 1=American Indian/Alaska Native 2=Asian 3=Black or African American 4=Native Hawaiian or other Pacific Islander 5=White Are you a parent/caregiver of a child with FAS/FASD? 1=Yes 2-No	If you are a PROFESSIONAL, please circle the one that best represents your current position: PHYSICIAN 1=OB/GYN 2=Geneticist 3=Pediatrician 4=Psychiatrist 5=Family Physician 6=Internist 7=Preventive Medicine 8=Occupational Medicine 9=Addiction Medicine 10=Physician, other Specify ____________(10a) OTHER MEDICAL 11=Dentist 12=Physician Assistant 13=Nurse (NP, RN, LPN) 14=Other Medical Specify _____________(14a) ALLIED HEALTH 15=Psychologist (unspecified) 16=Rehabilitation Psychologist 17=Clinical Psychologist 18=Community Psychologist 19=Counselor (including AODA Counselor) 20=Social worker 21=OT/PT/SLP 22=Medical Technologist 23=Other allied health professional: Specify _____________ (23a) OTHER 24=Public Health 25=Special Educator 26=Other Educator 27=Administrator 28=Corrections 29=Lawyer/Judge 30=Scientist 31=Prevention 32=Other: Specify ______________ (32a)	If you are a STUDENT OR RESIDENT, please circle all that apply: MEDICAL AND NURSING STUDENTS 1a=Med 1 1b=Med 2 1c=Med 3 1d=Med 4 1e=Clerkship 1f=Preceptorship 2=Nursing 3=Dental ALLIED HEALTH 4=Allied Health (inc. OT/PT SLP/Social Work, Counseling, etc.) RESIDENT 5=OB/GYN 6=Genetics 7=Pediatric 8=Psychiatry 9=Family Medicine 10=Internal Medicine 11=Preventive Medicine 12=Occupational Medicine 13=Addiction Medicine 14=Dental 15=Other resident: Specify ________ (15a) OTHER STUDENT 16=Pre-doctoral student 17=Graduate Student 18=Undergraduate Student 19=Other Specify _______ (19a)

THANK YOU!