Midwest Utilization of Curriculum Pre-test and Follow-up - Word

Attachment F8 Form Approved
OMB No. XXXX-XXXX
Exp. Date xx/xx/xxxx

Pre-Evaluation

Utilization of FAS/FASD Curriculum

Name: _______________________________________________________________

Email: ­­­­­­­­­­­­­_______________________________________________________________

University: ___________________________________________________________

Department/Program: __________________________________________________

If you are representing a residency program, skip this section and go to the bottom of the page.

1. Number of courses in your department that teach any FASD competencies. _____

2. Number of courses that you teach that address any FASD competencies. ______

3. Please provide the total number of minutes you spend teaching each competency in your courses. If the competency isn’t taught currently, write in “0”.

Competency # Minutes

1. FAS Foundation ______

2. Screening/Brief Interventions ______

3. Models of Addiction ______

4. Biological effects on fetus ______

5. Screening, Diagnosis, Assess ______

6. Treatment Across Lifespan ______

7. Ethical, Legal, Policy Issues ______

If you are in a residency program, please complete the box below for the entire program. Please do not count precepting, only scheduled didactic sessions. If the competency is not taught currently, write in “0”.

Competency # Minutes

1. FAS Foundation ______

2. Screening/Brief Interventions ______

3. Models of Addiction ______

4. Biological effects on fetus ______

5. Screening, Diagnosis, Assess ______

6. Treatment Across Lifespan ______

7. Ethical, Legal, Policy Issues ______

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)