Healthcare Organization Survey - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Healthcare Organization Utilization Survey (Online)

You are invited to participate in this survey for healthcare organization representatives. The purpose of the survey is to gather information about the utilization of various resources that you organization may have been offered to support provider practice behaviors related to patient alcohol use. Your feedback is important as it will help assess the usefulness of these resources and inform refinements.

This survey will take approximately 30 minutes to complete. Your participation is voluntary and responses will be kept secure. There are no costs associated with participating nor will you directly benefit from participation.

1. What activities or resources from the CDC FASD Project has your organization been offered? (Select all that apply.)

   1. Training on FASD identification and diagnosis

      1. If yes

The training on FASD identification and diagnosis has been offered to which of your organization’s provider disciplines? (Select all that apply.)

1. Nurses

2. Physicians, family medicine

3. Physicians, ob/gyn

4. Physicians, pediatrics

5. Physicians, other (Please specify: ________________)

6. Medical assistants

7. Social workers

8. Other. (Please specify: _____________________)

1. Training on alcohol screening and brief intervention

   1. If yes

The training on alcohol screening and brief intervention has been offered to which of your organization’s provider disciplines? (Select all that apply.)

1. Nurses

2. Physicians, family medicine

3. Physicians, ob/gyn

4. Physicians, pediatrics

5. Physicians, other (Please specify: ________________)

6. Medical assistants

7. Social workers

8. Other. (Please specify: _____________________)

1. Implementation guides or technical assistance

2. Electronic health record technical assistance/resources

3. Provider resources for FASD diagnosis/care (e.g., pocket guides)

4. Provider resources for alcohol screening (e.g., pocket guides)

5. Provider resources for brief intervention (e.g., pocket guides)

6. Position statements from national professional organizations

7. Clinical guidelines

8. Target communications for dissemination (e.g. social media messages, infographics, newsletters)

9. Other (Please specify: ___________________________)

2. Has your organization used any of the activities or resources from the CDC Project?

YES NO

1. {If 2 = yes} Which activities or resources has your organization used? {List will be only those checked “yes” from Question 1.}

{For each checked yes in 2a}

1. How useful was {activity/resource name}? 1 (not at all useful) to 5 (very useful)

2. What was the impact of using {activity/resource name}?

3. How could {activity/resource name} be improved?

2. {If 2 = no} What were the barriers to using these activities or resources?

Lack of time

Competing clinical priorities

Lack of resources (e.g. fiscal, space, technological)

No/limited buy-in from staff

Incompatible internal policy/culture

Lack of leadership support

Training needs

Technical assistance needs

Other. Please specify: ___________________________

1. What changes to the activities/resources would make you more likely to use them?

3. What changes has your organization made with regard to FASD awareness, identification, and diagnosis?

   1. How will you ensure that these changes are sustained over time?

   2. What additional changes do you hope to make?

4. What changes has your organization made with regard to alcohol screening and brief intervention?

   1. How will you ensure that these changes are sustained over time?

   2. What additional changes do you hope to make?

5. What other activities or resources would be useful to your organization in implementing changes toward FASD-informed practice, including prevention of risky alcohol use?

CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS

D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).