Form
Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/xxxx
Medical Assistants
Follow-up Survey
The course you are taking will contain presentation materials developed by the Mountain Plains Practice and Implementation Center
(PIC), located at the University of Nevada, Reno. These materials are based on content developed by the Centers for Disease Control and Prevention (CDC).
This survey does not ask you for any personal identifying information and the results will only be used to assist us in determining the effectiveness of the course. The course instructor will not be able to view your individual responses or know if you completed this survey. Likewise, you are not required to complete this survey and your participation in this class will not be affected regardless of your decision.
Thank you for your time and enjoy the class.
Personal ID code: First letter of your mother’s first name ____
First letter of your mother’s maiden name ____
First digit of your social security number ____
Last digit of your social security number ____
Demographics
Are you (choose one)
Male
Female
Are you Hispanic or Latino(a)?
Yes
No
How do you describe your race? (Check all that apply.)
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
In which state do you work? (specify) __________________________________
In what type of medical setting do you work?
OB/GYN
Family medicine
Other (specify) _______________________________________________________________________________________
The scenarios below describe alcohol use-related behaviors of two women. Please read each scenario carefully and respond to the questions that follow.
Scenario 1
Over the past few months, Sally has started to drink more than her usual amount of alcohol. In fact, she has noticed that she now needs to drink twice as much in order to get the same effect. Several times she has tried to cut down or stop drinking. However, each time she tried she became very agitated and couldn’t sleep so would start drinking and the symptoms would go away. Her family has complained that she is often hung over, moody, and has become unreliable – making plans one day and cancelling them the next. In fact, they report that she frequently calls them while intoxicated and has no memory of the calls or what she promised the next day.
Please respond to the following by circling the number that most closely corresponds to your reaction to this situation.
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Scenario 2
During the past year, Jessica has started to drink more than her usual amount of alcohol. In fact, she has noticed that she now needs to drink twice as much in order to get the same effect. Three months ago, Jessica found out that she is pregnant and her doctor told her she should not drink alcohol during her pregnancy. Jessica has tried but so far has not been able to stop drinking. Some of Jessica’s friends told her that when they were pregnant the taste and/or smell of alcohol made them sick. Jessica was hoping that she would have the same reaction, but that has not been the case. Out of concern for Jessica’s health and the health of her baby, her family has tried several times to talk with her about it. However, they are telling her that she is being selfish and not behaving in the best interest of her child. This approach is only increasing how guilty and ashamed Jessica is feeling about not being able to stop. As a result, Jessica has become very secretive about her drinking, sneaking a drink whenever she has a chance.
Please respond to the following by circling the number that most closely corresponds to your reaction to this situation.
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The following items deal with factors related to fetal alcohol spectrum disorders.
Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy.
True
False
FASD is preventable if a woman does not drink during her pregnancy.
True
False
The effects for FASD are always visible.
True
False
When is it safe to drink alcohol during pregnancy?
During the first three months
During the last three months
Once in a while
Never
How much alcohol is safe to drink during pregnancy?
One glass of wine
Two light beers
One shot of hard alcohol
None of the above
Screening for excessive alcohol use during pregnancy can be an effective strategy in reducing FASD.
True
False
How often do you talk to your patients or their parents/caregivers about prevention of excessive alcohol use?
Never
Occasionally
About Half the Time
Frequently
Always
The practice in which I work has a protocol to screen all patients about their alcohol use.
Yes (Go to Q13)
No (Go to Q18)
Don’t Know (Go to Q18)
Not applicable to the patients in my practice setting (Go to Q18)
What does initial patient SCREENING for alcohol use consist of in your practice?
Informal questions (Do you drink? How often/much do you drink?, etc.)
Formal screening tool or evidence-based screening instruments (AUDIT, AUDIT-C, DAST, CAGE, etc.)
I don't know.
Who generally conducts the initial SCREEN for alcohol? (Check all that apply.)
Nurse (including nurse practitioner)
Social worker
Behavioral health specialist (coach)
Psychologist
Physician
Medical Assistant
Other/Specify or Comment ____________________
Is screening for alcohol use followed by some type of intervention in your practice? (Check all that apply.)
No, there is no patient education or intervention done following the initial screening. (Go to Q18)
Yes, all patients are given educational materials/information on “safe” levels of alcohol and health risks associated with consuming too much alcohol.
Yes, patients who screen positive for risky alcohol use are asked follow-up questions and provided brief counseling.
Yes, patients who screen positive for risky alcohol use are asked follow-up questions and provided with additional resources (e.g., a list of treatment and/or counseling services in the community).
Who generally does the intervention in your practice? (Check all that apply.)
Physician
Physician’s Assistant
Psychologist
Social worker
Behavior health specialist (coach)
Nurse (including nurse practitioner)
Other, please specify _________________
No one intervenes, to my knowledge
Does your practice bill for screening and brief intervention services?
Yes
No
Not sure
On a scale of 0-10 with 0 meaning “Completely Disagree” and 10 meaning “Completely Agree” to what extent do you agree with the following statements:
Alcohol consumption during pregnancy is more prevalent in:
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Which of the following two statements best corresponds with your personal viewpoint (please check only ONE box).
Occasional consumption of one standard drink 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.
On a scale from 0 to 4 where 0 means you completely disagree with the statement and 4 means you completely agree, to what extent do you disagree or agree with the following statements. (Circle one number per row).
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On a scale from 0 to 10 where 0 means “Not confident in my skills” and 10 means “Totally confident in my skills,” how confident are you in your skills to do the following? (Circle one number per row).
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To what extent to you agree with the following statements? |
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Thanks for your participation!!!
CDC estimates the average public reporting burden for this collection of information as 10 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).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Addiction Counseling Academic Program Survey |
Author | Samantha |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |