Form Approved
OMB No. 0920XXXX
Exp. Date xx/xx/20xx
OBGYN
SBI Knowledge and Agency
Instructions:
For each item, please circle the response that best indicates how you
feel today. Your responses will be kept
secure, and will be summarized only in aggregate with those of other
respondents. Individual, identifiable responses will NOT be shared.
I am confident in my ability to assess patients' Readiness to Change their drinking behavior.
1
2 3 4
5 6 7
Strongly Strongly
Agree
Neutral Disagree
My interaction with a patient can make a difference regarding their use of alcohol.
1
2 3 4
5 6 7
Strongly Strongly
Agree
Neutral Disagree
Patients’ concerns
about confidentiality affect their willingness to be open and honest
when asked about alcohol use before and during pregnancy.
1 2 3 4
5 6 7
Strongly Strongly
Agree
Neutral Disagree
Most pregnant patients decrease or stop alcohol use when they realize there is a risk to the pregnancy or the child.
1 2 3 4 5 6 7
Strongly
Strongly
Agree
Neutral Disagree
CDC estimates the average public reporting burden for this collection of information as 2 minutes per survey, 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 D74,
Atlanta, Georgia 30333; ATTN: PRA
(0920XXXX).
NIAAA recommended daily and
weekly guidelines for low-risk drinking for WOMEN in
general are:
___ drinks per day
(a) ___ drinks per week (b)
Please give your best estimates for “standard drink” amount for each of the following types of alcohol:
___ oz. of wine (a) ___ oz. of beer (b) ___oz. of hard liquor (c)
Thank
You for Completing!
OBG-KAsupplement.SpragueDJ.v2
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | spragued |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |