Great Lakes Physicians Clinical Experience B

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E14. Great Lakes FASD Regional Training Center

Clinical Experience B 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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1

(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:

2

(continue)

4. On a scale of 1-10 where 1 means “Very Poor” and 10 means “Excellent,” how would you rate the clinical preceptorship you have just received in assessing Fetal Alcohol Spectrum Disorders (FASD)?

1 2 3 4 5 6 7 8 9 10

4. What suggestions do you have for improving this training?

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3

(over)

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 for your participation in our Great Lakes

FASD Regional Training Center Clinical Training

Date Entered:__________________

By__________________________

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