AAP 3 Month Follow-up Survey

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Q1
Form Approve
OMB No. 0920-XXX
Exp. Date XX/XX/20X

Thank you for completing the training on fetal alcohol spectrum disorders (FASD) a few
months ago. 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 impac
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 identifiable 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 is voluntary. You may decline to answer any questions and you have the
right to stop the survey at any time.
Please submit questions to the project partners at [email protected].
CDC estimates the average public reporting burden for this collection of information as 2 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).

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Q2
Unique identifier information (to help us match your previous surveys):
First 2 letters of your mother's
maiden name:
2-digit month of your birth:
Last 2 digits of your social security
number:

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Q3
In what State do you practice? Use the drop down menu to find your State.

AL

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Never

Rarely

Sometimes

Usually

Always

a. Inquire routinely about prenatal exposure to alcohol
b. Identify patient as someone who may have one of the
FASDs
c. Diagnose patient as someone who may have one of the
FASDs
d. Refer patient for diagnosis and/or treatment services
e. Manage/coordinate the treatment of patient

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Q5
During the past three months, did you diagnose any children with one of the fetal alcohol spectrum disorders (FASDs)?
Yes
No

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Q6
If yes, which diagnostic schema (if any) did you use to support your diagnosis:
Institute of Medicine criteria
American Academy of Pediatrics algorithm and/or toolkit
Digit Diagnostic Code (University of Washington)
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Other schema (please specify)

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I did not use any particular schema

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Q7
During the past three months, did you refer any children for FASD assessment?
Yes
No

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Q8
As a result of participating in the FASD learning activity, did you intend to make a change in your practice?
Yes
No

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Q10
Did you encounter any barriers to making a change in your practice?
Yes
No

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Q11
If YES, please describe:

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Q12
Thank you for taking the time to complete this survey!

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2/10/2016