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Q1
Form Approve
OMB No. 0920-XXX
Exp. Date XX/XX/20X
Thank you for competing the training on fetal alcohol spectrum disorders (FASD). 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 7 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 you
information becoming known to individuals outside the AAP.
Your participation 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].
The public reporting burden of this collection of information is estimated to average 7 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 respon
to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any 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).
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Q2
Unique identifier information (to help us match your pre- and post-training surveys).
First 2 letters of your mother's
maiden name:
2-digit month of your birth:
Last 2 digits of your social security
number:
Q3
In what State do you practice? Use the drop down menu to find your State.
AL
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Q4
How would you rate your overall satisfaction with this course?
Not at all Satisfied
A little Satisfied
Moderately Satisfied
Satisfied
Completely Satisfied
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Q5
How well did this course meet your educational needs?
Not at all Met
Slightly Met
Met
Somewhat Exceeded
Exceeded
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Q6
Will you recommend this course to your colleagues?
Yes (Why?)
No (Why not?)
Q7
Please offer suggestions for improvement:
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Q8
To what extent do you agree the following educational objectives were met? (Mark one response per row)
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
a. Explain alcohol metabolism and
pharmacology (absorption, distribution,
metabolism, and elimination).
b. Describe birth defects associated
with alcohol use.
c. Describe alcohol-induced injuries on
developing organ systems.
d. Describe cellular responses to
alcohol exposure.
e. Explain putative biomedical
mechanisms.
f. Describe genetic variants and
markers for susceptibility for FASDs.
g. Describe the diagnostic criteria and
approaches for diagnostic for each
condition along the continuum of
FASDs, including ARND, ND-PAE,
FAS, pFAS, and ARBD.
h. Distinguish major physical and
neurobehavioral features for differential
diagnosis of FASDs from other genetic
and behavioral disorders as well as
relevant comorbidities.
i. Describe how to obtain information
about prenatal exposure to alcohol from
patient to parents as part of patient
screening.
j. Identify potential referrals, secondary
conditions, risk factors, and care
planning for individuals with FASDs.
k. Identify potential referrals, secondary
conditions, risk factors, and care
planning for individuals with FASDs.
l. Explain various treatment approaches
for FASDs.
m. Explain support services and
resources for families and providers.
n. Explain the importance of screening
every patient for a history of prenatal
alcohol exposure at birth and during
their first clinic visit.
o. Discuss the stigma associated with
assessing a patient for effects of
prenatal alcohol exposure for clinicians,
parents/ caregivers, affected individuals
and society.
p. Know key state and federal policies
regarding assessing all patients for
FASDs.
q. Name the 4 diagnostic criteria for ND
-PAE.
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Q9
Fetal alcohol spectrum disorders (FASDs) is an umbrella term describing the range of effects that can occur in an individua
who was exposed prenatally to alcohol.
True
False
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Q10
Which of the following are the primary facial dysmorphic features associated with fetal alcohol syndrome? (Check all that
apply)
Wide inner canthal distance
Short palpebral fissures
Full lips
Smooth philtrum
Thin upper lip
Flaring nares
Don't know/unsure
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Q11
The diagnosis of "neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)" as identified in the
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5):
a. Requires recognition of neurocognitive impairment, self-regulation impairment, and deficits in adaptive
functioning
b. Can be diagnosed without knowledge of confirmed prenatal alcohol exposure
c. Includes recognition of the 3 primary morphologic features of prenatal alcohol exposure
d. Is the least common manifestation of prenatal alcohol exposure
e. All of the above
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Q12
Which of the following could indicate that a child may have been exposed to alcohol prenatally? (Check all that apply)
Growth deficiencies
Clinically significant abnormalities in neuroimaging and/or a history of seizures
Cognitive/developmental deficiencies or discrepancies
Executive function deficits
Delays in gross/fine motor function
Problems with self-regulation/self-soothing
Delayed adaptive skills
Confirmed history of alcohol exposure in utero
Don't know/unsure
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Q13
Which of the following approaches/care strategies is not applicable for children diagnosed with an FASD?
Regularly scheduled follow-up in the medical home to anticipate/address needs across the lifespan.
Refer child’s case to therapist to provide all follow-up and lifelong monitoring because traditional behavioral
therapies work best for children with an FASD.
Evaluation by a psychologist to assess neurocognitive functioning, self-regulation, and adaptive functioning
skills.
Medication management for co-occurring conditions as needed to optimize care.
All of the above are applicable approaches/care strategies for children with an FASD.
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Q14
To what extent do you agree with the following statements? (Mark one response per row)
Neither
Agree
nor
Stro
Strongly
Disagree Disagree Disagree Agree Agr
a. Prenatal alcohol exposure is a potential cause of growth impairment
b. Prenatal alcohol exposure is a potential cause of a physical, cognitive
and behavioral health problems
c. Diagnosis of one of the FASDs may confer a negative stigma to a child
and/or his or her family
d. Diagnosis of one of the FASDs only needs to be considered for certain
populations
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Q15
In your opinion, how much alcohol is safe to drink during pregnancy?
Q16
Which of the following two statements below best corresponds with your personal viewpoint. Please check only ONE.
Occasional consumption of one standard alcoholic drink per day or less (i.e., 1.5 oz. hard liquor, 12 oz. of beer
or 5 oz. of wine) during pregnancy is not harmful to the mother or the fetus.
Pregnant women or women who are trying to become pregnant should completely abstain from consuming
alcohol.
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Q17
To what extent do you agree with the following statements about alcohol consumption during pregnancy? (Mark one
response per row)
Alcohol consumption during pregnancy...
Strongly
Disagree
Disagree
Neither
Agree nor
Disagree
Agree
Strongly
Agree
a. Is more prevalent in women with lower incomes
b. Is more prevalent in women with higher incomes
c. Does not vary between income levels
d. Is more prevalent in women with lower levels of education
e. Is more prevalent in women with higher levels of education
f. Does not vary between education levels
g. Is more prevalent in African-American women
h. Is more prevalent in American Indian women
i. Is more prevalent in Anglo-white women
j. Is more prevalent in Asian-American women
k. Is more prevalent in Hispanic/Latina-American women
l. Does not vary between ethnic or racial groups
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Q18
How confident are you in your skills to do the following? (Mark one response per row)
Not at all
A Little Moderately
Confident Confident Confident Confident Completely
in my
in my
in my
in my
Confident
Skills
Skills
Skills
Skills
in my Skills
a. Inquire about potential prenatal alcohol exposure for
pediatric patients
b. Identify persons with possible FAS or other prenatal
alcohol-related disorders
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
d. Utilize resources to refer patients for diagnosis and/or
treatment for FAS(D)
e. Manage/coordinate the treatment of persons with FASDs
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Q19
How willing are you to do the following? (Mark one response per row)
Not at all
Willing
A little
Willing
Moderately
Willing
Willing
Completely
Willing
a. Inquire about potential prenatal alcohol exposure for
pediatric patients
b. Identify persons with possible FAS or other prenatal
alcohol-related disorders
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
d. Utilize resources to refer patients for diagnosis and/or
treatment for FAS(D)
e. Manage/coordinate the treatment of persons with FASDs
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Q20
As a result of participating in this learning activity, do you intend to make change in your practice?
Yes
No
Q21
If yes, describe what you will do differently in practice and how you will accomplish this change.
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Q22
Do you feel a commercial product, device, or service was inappropriately promoted in the educational content?
Yes (please comment)
No
Q23
Please feel free to comment on your response to any of the questions in this survey or provide any feedback.
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Q24
Please Take a Moment to Tell Us About Yourself.
Q25
Are You... (select one)
1. Male
2. Female
3. Transgender
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Q26
With what racial or cultural group(s) do you identify yourself? (Mark all that apply)
White, non-Hispanic/Latin@
Hispanic/Latin@
Black/African American, non-Hispanic/Latin@
Asian
Native Hawaiian or other Pacific Islander
American Indian/Alaska Native
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Q27
What year did you complete or will you complete your training:
Q28
Are you, or will you be a:
Primary care pediatrician
Developmental/behavioral pediatrician
Geneticist
Other pediatric sub-specialty (Specify)
Family Physician
Other (Specify)
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Q29
Please indicate your primary employment site setting, that is, the setting where you spend most of your time. Mark only ON
response.
Self-employed solo practice
Two physician practice
Pediatric group practice, 3-10 pediatricians
Pediatric group practice, >10 pediatricians
Multispecialty group practice
Health maintenance organization (staff model)
Medical school or parent university
Non-profit community health center
Non-government hospital or clinic
City/county/state government hospital or clinic
US government hospital or clinic
Other (Specify)
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Q30
Please describe the community in which your primary practice/position is located?
Urban, inner city
Urban, not inner city
Suburban
Rural
Q30
Thank you for taking the time to answer this survey!
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2/10/2016
| File Type | application/pdf |
| File Title | https://uwmadison.co1.qualtrics.com/CP/?ClientAction=EditSurvey |
| Author | GXW827 |
| File Modified | 2016-02-19 |
| File Created | 2016-02-10 |