Midwest Continuing Education Follow-up

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

MRFASTC - Continuing Education Event-Practice Behaviors/Self-Efficacy
1. MRFASTC ­ Practice Behaviors/Self­Efficacy

Thank you for attending the Midwest Regional Fetal Alcohol Spectrum Disorders Training Center's Continuing Education 
Event approximately 3 months ago. 

The purpose of this follow­up is to evaluate the scope of FASD education, skill levels, and FASD practice­based self­
efficacy in various health professions.  

Please take about 5 minutes to answer the following questions.  

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

j Yes
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j No
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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?
(Choose only one number per row)
10 ­ 

0 ­ Not 
confident 
in my 

Totally 
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in my 

skills
Screen women for risky or hazardous 

confident 
skills

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drinking
Educate pregnant women about the effects 
of alcohol on their babies
Conduct brief interventions for reducing 
alcohol consumption
Utilize resources to refer patients who need 
formal treatment for alcohol abuse

3. In your current position, do you provide services to individuals who may be at risk of an
FASD?

j Yes
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j No
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MRFASTC - Continuing Education Event-Practice Behaviors/Self-Efficacy
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?
(Choose only one number per row)
10 ­ 

0 ­ Not 
confident 
in my 

Totally 
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2

3

4

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in my 

skills
Identify persons with possible FAS or other 

confident 
skills

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prenatal alcohol­related disorders
Diagnose persons with possible FAS or other 
prenatal alcohol­related disorders
Utilize resources to refer patients for 
diagnosis and/or treatment services
Manage/coordinate the treatment of persons 
with FASDs

5. How did you use the information you received at the training 3 months ago?
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6. What additional information do you need to make changes in your practice related to the
prevention, identification, and treatment of FASDs?
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