TCU Organizational Readiness Survey - word
L3 TCU Organizational Readiness Survey.doc
Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships
TCU Organizational Readiness Survey - word
OMB: 0920-1129
TCU Organizational Readiness Survey
Instructions
This survey asks questions about how you see yourself as a team member and how you see your health clinic. It begins on the next page with a short demographic section that is for descriptive purposes only. The Anonymous Linkage Code is requested so that information you give now can be “linked” to your responses to similar questions you may be asked later.
To complete the form, please mark your answers by marking the appropriate circles. If you do not feel comfortable giving an answer to a particular statement, you may skip it and move on to the next statement.
TCU/Medical ORC Survey
The anonymous linkage code below will be used to match data from different evaluation forms without using your name or information that can identify you.
Please complete the following items for your anonymous code:
First letter in mother’s first name: |___| First letter in father’s first name: |___|
First digit in your social security number: |___| Last digit in your social security number: |___|
Today’s Date: |___|___||___|___||___|___| Are you: Male Female
mo day yr
Your Birth Year: 19 |___|___|
Are you Hispanic or Latino?
No Yes
Are you: [MARK AS MANY AS APPLY]
American Indian or Alaska Native Black or African American
Asian White
Native Hawaiian or other Pacific Islander
Highest Degree Status: [mark one]
No high school diploma or equivalent Bachelor’s degree
High school diploma or equivalent Master’s degree
Some college, but no degree Doctoral degree or equivalent
Associate’s degree Other (medical assistant, RN, post-doctorate)
Discipline/Profession: [mark all that apply]
Physician Other Human Services Clerk
Physicians Assistant Resident RT, PT, EKG
Nurse Practitioner Intern Pharmacy
Nursing (LVN, RN) Student Interpreter
PCT, NA Administration Other (specify)
Social Work/LCDC Manager
If Appropriate, List Area of Specialization:
(Ex. Internal Medicine, OB-GYN, etc.) ____________________
How long have you been in your present job?
less than 1 year 1 to 3 years over 3 years
TCU/ORC Survey
Please fill in the circle that shows your answer to each item.
Strongly Strongly
Disagree Disagree Undecided Agree Agree
(1) (2) (3) (4) (5)
My unit needs guidance in –
1. identifying patients who need alcohol
and drug services.
2. matching patient needs with alcohol
and drug services.
3. measuring patient progress relating to
alcohol and drug use.
4. developing services to address alcohol and
drug behaviors
presented by our patients .
5. raising overall quality of screening and
brief interventions
for patients with
alcohol and drug problems.
Current pressures to make changes to
identify, advise, and refer patients with
alcohol and drug behaviors come from-
6 . patients.
7. staff members.
8. supervisors or managers.
9. agency board members.
10. community action groups.
11. funding and oversight agencies.
12. accreditation or licensing authorities.
13. professional associations/colleagues.
14. self.
How strongly do you agree or disagree
with each of the following statements?
15. I have the skills needed to effectively
identify and
address patients with alcohol
and drug problems.
16. The leadership here fully trusts
my professional judgment.
17. There is too much friction among
staff members.
18. Ideas and suggestions from staff get fair
consideration
by administrative leaders.
19. My duties are clearly related to addressing
the needs of
patients who use alcohol and
drugs.
20. I consistently plan ahead
and carry out my plans.
21. I am under too many pressures
to do my job effectively.
22. Clinicians here are given broad authority
in treating
their own clients.
23. Staff here are always quick to help one
another when
needed.
Strongly Strongly
Disagree Disagree Undecided Agree Agree
(1) (2) (3) (4) (5)
24. Mutual trust and cooperation among staff
in this unit are
strong.
25. I am willing to try new ideas even
if some staff members
are reluctant.
26. Learning and using new procedures
are easy for me.
27. This medical facility operates with clear goals
and
objectives.
28. Staff members often show signs
of stress and strain.
29. I usually accomplish whatever
I set my mind on.
30. It is difficult to change procedures here
to meet new
conditions.
31. Clinicians here often try out
different techniques to
improve
their effectiveness.
32. The formal and informal communication
channels here work
very well.
33. I am sometimes too cautious or slow
to make changes.
34. Staff members are given too many
rules here.
35. Program staff are always kept
well informed.
36. More open discussions about program
and clinical issues are
needed here.
Strongly Strongly
Disagree Disagree Undecided Agree Agree
(1) (2) (3) (4) (5)
37. I frequently hear staff discussing ideas
for improving
procedures or treatment.
38. I am effective and confident
in doing my job.
39. Some staff here do not do their fair share
of work.
40. The general attitude here is to use new
and changing
technology.
41. Staff members always feel free to
ask questions and
express concerns
in this medical facility.
42. Staff frustration is common here.
43. The leadership here has a clear plan
for implementing
alcohol and drug
services for our patients.
44. I am encouraged here to try
new and different techniques.
45. I am able to adapt quickly
when I have to shift focus.
Thank you for your time and thoughtful responses. We value your input.
© Copyright 2002 TCU Institute of Behavioral Research, Fort Worth, Texas. All rights reserved.
| File Type | application/msword |
| File Title | Informed Consent to Participate in Research |
| Author | cookms |
| Last Modified By | Green, Patricia P. (CDC/ONDIEH/NCBDDD) |
| File Modified | 2016-02-19 |
| File Created | 2016-02-19 |
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