Great Lakes Physicians Clinical Experience A

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Exp. Date xx/xx/xxxx

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E13. Great Lakes FASD Regional Training Center

Clinical Experience A Evaluation Form

Please review and respond to the questions below. Your responses are essential to us as we work to make our training activities as meaningful as possible. Your responses will be treated confidentially.

1. On a scale from 1-10 where 1 means “Not confident in my skills” and 10 means

“Totally confident in my skills,” how confident are you in your skills to recognize and assess FASD in your patient population.

1 2 3 4 5 6 7 8 9 10

1a. If you did not rate yourself a “10”, what would need to happen for you to

give yourself that rating? Please check all that apply.

 I need a better understanding of FASD concepts

 I need better skill at diagnosing

 I need more support from colleagues

 I need more information about where to refer a patient

 I need more time for a patient appointment

 I need to feel more comfortable bringing up the topic to patients and

family members

• I need to feel more comfortable brining up the topic to colleagues

• I need more practice

• I’d rather refer

• Other: ­

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(over)

2. On a scale of 1-10 where 1 means “Not at all Ready” and 10 is “Totally Ready,” how ready are you at the present time to include clinical assessment in your professional practice.

1 2 3 4 5 6 7 8 9 10

3. On a scale of 1-10 where 1 means “I am not likely to include clinical assessment for FASD” and 10 means “I am very likely to include clinical assessment for FASD.” How likely are you to include FASD assessment with your patient population?

1 2 3 4 5 6 7 8 9 10

3a. If you did not rate yourself a “10”, what would need to happen for you to

give yourself that rating? Please check all that apply.

 I need a better understanding of FASD concepts

 I need better skill at diagnosing

 I need more support from colleagues

 I need more information about where to refer a patient

 I need more time for a patient appointment

 I need to feel more comfortable bringing up the topic to patients and

family members

• I need to feel more comfortable brining up the topic to colleagues

• I need more practice

• I’d rather refer

• Other: ­

THANK YOU for participating in this Clinical Training.

Date Entered:__________________

By__________________________

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