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pdfThis document contain screenshots for the AAP Six Month Follow Up Training Evaluation Survey.
As noted in the request for approval of non-substantive changes, respondents to this survey see a
subset of the questions depending on the training they take prior to receiving the survey. There are
three trainings that respondents may take, so there are three “paths” through the survey. Screenshots
for these paths are presented separately in this document, as follows:
1. Six Month Follow Up Training Survey Path 1 (Training: Screening, Assessment, and Diagnosis)
2. Six Month Follow Up Training Survey Path 2 (Training: ND-PAE)
3. Six Month Follow Up Training Survey Path 3 (Training: Treatment Across the Lifespan)
AAP Six Month Follow Up Training Evaluation Survey
Survey Path 1
Training: Screening, Assessment, and Diagnosis
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Page 1 of 6
Peds DSW 6-month survey - Screeni…
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Peds DSW 6-month survey - Screening, Assessment and Diagnosis
This survey is currently LOCKED to prevent invalidation of collected responses! Please unlock your survey to
make changes.
Default Question Block
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Form Approved
OMB No. 0920-1129
Exp. Date 08/31/2019
Thank you for completing the training on fetal alcohol spectrum disorders (FASD) about
six months ago. We would like to invite you to complete a follow-up 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 5 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 in this survey 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].
The public reporting burden for this collection of information is estimated to average 5 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 (0920-1129).
Page Break
Unique identifier information (to help us match your previous surveys)
First 2 letters of your mother's
maiden name:
Month of your birth:
Last 2 digits of your social
security number:
State in which you practice. Use the drop down menu to find your State.
AL
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Page 2 of 6
Page Break
6Mk6
Which of the following are the primary facial dysmorphic features associated with fetal
alcohol syndrome (FAS)? (Check all that apply)
Wide inner canthal distance
Short palpebral fissures
Full lips
Smooth philtrum
Thin upper lip
Flaring nares
Don't know/unsure
Page Break
6Mk7
The diagnosis of "neurobehavioral disorder associated with prenatal alcohol exposure" (NDPAE) 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
Page Break
6Mk9
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.
Page Break
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Page 3 of 6
To what extent do you agree with the following statements? (Mark one response per row)
6M10 c,d
Neither
Agree
Strongly
nor
Stro
Disagree Disagree Disagree Agree Ag
a. Diagnosis of one of the FASDs may confer a negative
stigma to a child and/or his or her family
b. Diagnosis of one of the FASDs only needs to be considered
for certain populations
Page Break
In your opinion, how much alcohol is safe to drink during pregnancy?
6M11
Page Break
6M12
Please check which of the following two statements below best corresponds with your
personal viewpoint. Please mark 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.
Page Break
6M13 b, e, l
To what extent do you agree with the following statements about alcohol consumption during
pregnancy? (Mark one response per row)
Alcohol consumption during pregnancy...
Neither
Agree nor
Strongly
Disagree
Disagree
Disagree
Strongly
Agree
Agree
a. Is more prevalent in women with higher
incomes
b. Is more prevalent in women with higher
levels of education
c. Does not vary between ethnic or racial
groups
Page Break
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Page 4 of 6
How often do you do the following? (Mark one response per row)
6M14 a, b,
c, d
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
Page Break
How confident are you in your skills to do the following? (Mark one response per row)
6M16 a, b,
c
Not at all
A Little
Confident Confident Moderately Confident C
in my
in my
Confident
in my
C
Skills
Skills
in my Skills
Skills
in
a. Inquire about potential prenatal alcohol exposure for
pediatric patient
b. Identify persons with possible FAS or other prenatal
alcohol-related disorders
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
Page Break
How willing are you to do the following? (Mark one response per row)
6M17 a, b,
c
Not at
A
all
Little Moderately
Completely
Willing Willing
Willing
Willing
Willing
a. Inquire about potential prenatal alcohol exposure for
pediatric patient
b. Identify persons with possible FAS or other prenatal
alcohol-related
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
Page Break
6M18
yes=1 no=2
Is stigma a barrier as you consider assessing for prenatal alcohol exposure in your clinical
practice?
Yes
No
Page Break
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6M19
yes=1 no=2
Page 5 of 6
During the past six months, did you diagnose any children with fetal alcohol syndrome (FAS)
or one of the fetal alcohol spectrum disorders (FASDs)?
Yes
No
If yes, which diagnostic schema (if any) did you use to support your diagnosis:
6M19
schema
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
Page Break
During the past six months, did you refer any children for FASD assessment?
6M20
yes=1 no=2
Yes
No
Page Break
6M21
yes=1 no=2
As a result of participating in the FASD learning activity 6 months ago, did you make a change
in your practice?
Yes
No
If yes, describe what change you made:
6M21 text
Page Break
Did you encounter any barriers to making a change in your practice?
6M22
yes=1 no=2
Yes
No
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Page 6 of 6
If YES, please describe:
6M22
text
Page Break
Please feel free to comment on your response to any of the questions in this survey.
6M23
Thank you for taking the time to answer these questions!
Page Break
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AAP Six Month Follow Up Training Evaluation Survey
Survey Path 2
Training: ND-PAE
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Peds DSW 6-month survey - ND-PAE
Survey
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Data & Analysis
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Projects
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Survey Director
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Peds DSW 6-month survey - ND-PAE
This survey is currently LOCKED to prevent invalidation of collected responses! Please unlock your survey to
make changes.
Default Question Block
Block Options
Form Approved
OMB No. 0920-1129
Exp. Date 08/31/2019
Thank you for completing the training on fetal alcohol spectrum disorders (FASD) about
6 months ago. We would like to invite you to complete a follow-up 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 5 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 in this survey 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].
The public reporting burden for this collection of information as 5 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 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 (0920-1129).
Page Break
Unique identifier information (to help us match your previous surveys)
First 2 letters of your mother's
maiden name:
Month of your birthday:
Last 2 digits of your social
security number:
https://uwmadison.co1.qualtrics.com/ControlPanel/?ClientAction=EditSurvey&Section=SV... 5/3/2017
Edit Survey | Qualtrics Survey Software
Page 2 of 6
State in which you practice. Use the drop down menu to find your State.
AL
Page Break
6Mk6
Which of the following are the primary facial dysmorphic features associated with fetal
alcohol syndrome (FAS)? (Check all that apply)
Wide inner canthal distance
Short palpebral fissures
Full lips
Smooth philtrum
Thin upper lip
Flaring nares
Don't know/unsure
Page Break
6Mk7
The diagnosis of "neurobehavioral disorder associated with prenatal alcohol exposure" (NDPAE) 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
Page Break
6Mk9
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.
Page Break
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Edit Survey | Qualtrics Survey Software
Page 3 of 6
To what extent do you agree with the following statements? (Mark one response per row)
6M10 c, d
Neither
Agree
Strongly
nor
Stro
Disagree Disagree Disagree Agree Ag
a. Diagnosis of one of the FASDs may confer a negative
stigma to a child and/or his or her family
b. Diagnosis of one of the FASDs only needs to be considered
for certain populations
Page Break
In your opinion, how much alcohol is safe to drink during pregnancy?
6M11
Page Break
6M12
Please check which of the following two statements below best corresponds with your
personal viewpoint. Please mark 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.
Page Break
6M13 b, e, l
To what extent do you agree with the following statements about alcohol consumption during
pregnancy? (Mark one response per row)
Alcohol consumption during pregnancy...
Neither
Agree nor
Strongly
Disagree
Disagree
Disagree
Strongly
Agree
Agree
a. Is more prevalent in women with higher
incomes
b. Is more prevalent in women with higher
levels of education
c. Does not vary between ethnic or racial
groups
Page Break
https://uwmadison.co1.qualtrics.com/ControlPanel/?ClientAction=EditSurvey&Section=SV... 5/3/2017
Edit Survey | Qualtrics Survey Software
Page 4 of 6
How confident are you in your skills to do the following? (Mark one response per row)
6M16 a, b,
c
Not at all
A Little
Confident Confident Moderately Confident C
in my
in my
Confident
in my
C
Skills
Skills
in my Skills
Skills
in
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
Page Break
How willing are you to do the following? (Mark one response per row)
6M17 a, b,
c
Not at
A
all
Little Moderately
Completely
Willing Willing
Willing
Willing
Willing
a. Inquire about potential prenatal alcohol exposure for
pediatric patients
b. Identify persons with possible FAS or other prenatal
alcohol-related
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
Page Break
6M18
yes=1 no=2
Is stigma a barrier as you consider assessing for prenatal alcohol exposure in your clinical
practice?
Yes
No
Page Break
6M19
yes=1 no=2
During the past six months, did you diagnose any children with fetal alcohol syndrome or one
of the fetal alcohol spectrum disorders (FASDs)?
Yes
No
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Page 5 of 6
If yes, which diagnostic schema (if any) did you use to support your diagnosis:
6M19
schema
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
Page Break
During the past six months, did you refer any children for FASD assessment?
6M20
yes=1 no=2
Yes
No
Page Break
6M21
yes=1 no=2
As a result of participating in the FASD learning activity 6 months ago, did you make a change
in your practice?
Yes
No
If yes, describe what change you made:
6M21 text
Page Break
Did you encounter any barriers to making a change in your practice?
6M22
yes=1 no=2
Yes
No
If YES, please describe:
6M21 text
Page Break
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Page 6 of 6
Please feel free to comment on your response to any of the questions in this survey.
6M23
Thank you for taking the time to answer these questions!
Page Break
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AAP Six Month Follow Up Training Evaluation Survey
Survey Path 3
Training: Treatment Across the Lifespan
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Treatment Across the Lifespan: 6-M…
Survey
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Projects
Contacts
Library
Survey Director
Help
Reports
Treatment Across the Lifespan: 6-Month Follow-up Evaluation Survey
Default Question Block
Block Options
Form Approved
OMB No. 0920-1129
Exp. Date 08/31/2019
Thank you for completing the training on fetal alcohol spectrum disorders (FASD)
about six months ago. We would like to invite you to complete this follow-up 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 5 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].
The public reporting burden of this colletion of information is estimated to average 5 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 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 (0920-1129).
Page Break
Unique identifier information (to help us match your previous surveys)
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. Use the drop down menu to find your State.
AL
Page Break
https://uwmadison.co1.qualtrics.com/ControlPanel/?ClientAction=EditSurvey&Section=SV... 5/4/2017
Edit Survey | Qualtrics Survey Software
6Mk9
Page 2 of 4
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.
Page Break
To what extent do you agree with the following statement.
6M10 c
Strongly
Neither
Agree
nor
Stro
Disagree Disagree Disagree Agree
Ag
a. Diagnosis of one of the FASDs may confer a negative
stigma to a child and/or his or her family
Page Break
How often do you do the following?
P14e
Never Rarely Sometimes Usually Alway
a. Manage/coordinate the treatment of patient
Page Break
How confident are you in your skills to do the following? (Mark one response per line)
6M16 d, e
Not at all A Little
Confident Confident Moderately Confident C
in my
Skills
in my
Skills
Confident
in my Skills
in my
Skills
C
in
a. Utilize resources to refer patients for diagnosis
and/or treatment for FAS(D)
b. Manage/coordinate the treatment of persons with
FASDs
Page Break
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Page 3 of 4
How willing are you to do the following? (Mark one response per line)
6M17 d, e
Not at
A
all
Little Moderately
Completely
Willing Willing
Willing
Willing
Willing
a. Utilize resources to refer patients for diagnosis
and/or treatment for FAS(D)
b. Manage/coordinate the treatment of persons with
FASDs
Page Break
6M21
yes=1 no=2
As a result of participating in the FASD learning activity 6 months ago, did you make a change
in your practice?
Yes
No
If yes, describe what change you made:
6M20
text
Page Break
Did you encounter any barriers to making a change in your practice?
6M22 yes=
1 no-2
Yes
No
If YES, please describe:
6M21 text
Page Break
6M23
Please feel free to comment on your response to any of the questions in this survey or provide
any additional feedback.
Thank you for taking the time to answer these questions!
P
B
k
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Page 4 of 4
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| File Type | application/pdf |
| Author | Melanie Chansky |
| File Modified | 2017-05-05 |
| File Created | 2017-05-04 |