Midwest Continuing Education Pre-test

Attachment F4 Form Approved
OMB No. XXXX-XXXX
Exp. Date xx/xx/xxxx

Midwest Regional FASD Training Center – Continuing Education Event

Practice Behaviors/Self-efficacy, Pre-test

Email Address: __________________________________________________

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1. In your current position, do you provide services to women of childbearing age? Yes No

2. On a scale from 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
Screen women for risky or hazardous drinking	0	1	2	3	4	5	6	7	8	9	10
Educate pregnant women about the effects of alcohol on their babies	0	1	2	3	4	5	6	7	8	9	10
Conduct brief interventions for reducing alcohol consumption	0	1	2	3	4	5	6	7	8	9	10
Utilize resources to refer patients who need formal treatment for alcohol abuse	0	1	2	3	4	5	6	7	8	9	10

3. In your current position, do you provide services to individuals who may be at risk of an FASD? Yes No

4. On a scale from 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
Identify persons with possible FAS or other prenatal alcohol-related disorders	0	1	2	3	4	5	6	7	8	9	10
Diagnose persons with possible FAS or other prenatal alcohol-related disorders	0	1	2	3	4	5	6	7	8	9	10
Utilize resources to refer patients for diagnosis and/or treatment services	0	1	2	3	4	5	6	7	8	9	10
Manage/coordinate the treatment of persons with FASDs	0	1	2	3	4	5	6	7	8	9	10

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)