Form Approved
OMB No. 0920-XXXX
AMERICAN ACADEMY OF PEDIATRICS
3-MONTH FOLLOW-UP EVALUATION SURVEY
Thank you completing the training on fetal alcohol spectrum disorders (FASD) a few months. We would like to invite you to complete a post-training evaluation survey. We appreciate your willingness to help us evaluate the effectiveness of the training and its impact on your practice as you address the prevention, identification, and treatment of FASD.
This survey will take approximately 2 minutes to complete. Your responses will be kept secure and no individually identifying information will be included. Risks to participating in this survey are minimal and include the risk of your information becoming known to individuals outside the AAP.
Your participation in this survey is voluntary. You may decline to answer any question and you have the right to stop the survey at any time.
Please submit questions to the project partners at [email protected].
UNIQUE IDENTIFIER INFORMATION
First 2 letters of your mother’s maiden name ___ ___
Month of your birthday ___ ___
Last 2 digits of your social security number ___ ___
State in which you practice ___ ___
The public reporting burden of this collection of information is estimated to average 2 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)
PRACTICE QUESTIONS
How often do you do the following? (Mark one response per row)
|
Never |
Rarely |
Sometimes |
Usually |
Always |
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1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
During the past
three months, did you diagnose any children with fetal alcohol
syndrome (FAS) or one of the fetal alcohol spectrum disorders
(FASDs)?
☐ Yes ☐
No
If YES, please specify which diagnostic schema (if
any) you used to support your diagnosis:
☐
Institute of Medicine criteria
☐
American Academy of Pediatrics algorithm and/or toolkit
☐
Seattle 4-Digit Diagnostic Code (University of Washington)
☐
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
☐
Other schema (please specify) _____________________________
☐
I did not use any particular schema
During the past
three months, did you refer any children for FASD assessment?
☐
Yes ☐ No
As a result of
participating in the FASD learning activity, did you intend to make
a change in your practice?
☐
Yes ☐ No
If
yes, please describe what you did differently in practice over the
past 3 months:
Did you encounter any barriers to making a change in your practice?
☐ Yes ☐ No
If yes, please describe:
Thank you for taking the time to complete this survey!
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Georgiana Wilton |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |