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pdfThis document contain screenshots for the AAP Pre-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, leading to two “paths” through the survey. Screenshots for
these paths are presented separately in this document, as follows:
1. Pre-Training Survey Path 1 (Training: Screening, Assessment, and Diagnosis or ND-PAE) 1
2. Pre-Training Survey Path 2 (Training: Treatment Across the Lifespan)
1
Note that the Screening, Assessment, and Diagnosis survey screenshots are included as the example in this
document, but the content of the ND-PAE survey is identical.]
AAP Pre-Training Evaluation Survey
Survey Path 1
Training: Screening, Assessment, and Diagnosis or ND-PAE 1
1
Note that the Screening, Assessment, and Diagnosis survey screenshots are included as the example here, but the
content of the ND-PAE survey is identical.
Edit Survey | Qualtrics Survey Software
Peds DSW Pre-Training Evaluation S…
Survey
Distributions
Data & Analysis
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Projects
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Library
Survey Director
Help
Reports
Peds DSW Pre-Training Evaluation Survey - Screening, Assessment and
Diagnosis
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Default Question Block
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Form Approved
OMB No. 0920-1129
Exp. Date 08/31/2019
Thank you for your interest in fetal alcohol spectrum disorders (FASD). We would like to invite
you to complete a pre-training evaluation survey. We appreciate your willingness to help us
evaluate the effectivenss of the training and its impact on your practice as you address the
prevention, identification, and treatment of FASD.
This survey will take approximately 3 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 your 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 average public reporting burden for this collection of information is estimated to
average 3 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 identifyer to help us match pre and post-training responses:
First 2 letters of your mother's
maiden name:
Month of your birthday:
Last 2 digits of your social
security number:
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Page 2 of 5
State in which you practice. Use the drop down menu to find your State.
AL
Page Break
PK5
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
PK6
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
PK9
Which of the following approaches/care strategies is not applicable for children diagnosed
with an FASD?
a. Regularly scheduled follow-up in the medical home to anticipate/address needs across the
lifespan.
b. 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.
c. Evaluation by a psychologist to assess neurocognitive functioning, self-regulation, and
adaptive functioning skills.
d. Medication management for co-occurring conditions as needed to optimize care.
e. All of the above are applicable approaches/care strategies for children with an FASD.
Page Break
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Page 3 of 5
To what extent do you agree with the following statements? (Mark one response per row):
P10 c, d
Neither
Strongly
Disagree
Agree nor
Disagree Disagree
Strongly
Agree
Agree
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
P11
In your opinion, how much alcohol is safe to drink during pregnancy?
Page Break
Q12 1, 2
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.
Page Break
P14 b, e, l
To what extent do you agree with the following statements about alcohol consumption during
pregnancy? (Mark one response per row)
Neither
Strongly
Disagree
Agree nor
Disagree Disagree
Agree
Strongly
Agree
a. Is more prevalent in women with higher
income
b. Is more prevalent in women with higher levels
of education
c. Does not vary between ethnic or racial groups
Page Break
How often do you do the following? (Mark one response per row)
P15 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
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Page 4 of 5
How confident are you in your skills to do the following? (Mark one response per row)
P17 a, b, c
Not at all A Little
Confident Confident Moderately Confident Com
in my
Skills
in my
Skills
Confident
in my Skills
in my
Skills
Co
in m
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 resonse per row)
P18 a, b, c
Not at
all
A little Moderately
Willing Willing
Willing
Completely
Willing
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
P19 yes= 1
no=2
Is stigma a barrier as you consider assessing for prenatal alcohol exposure in your clinical
practice?
Yes
No
Page Break
P20 yes=1
no=2
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
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P20
schema
Page 5 of 5
If yes, which diagnostic schema (if any) did you use to support your diagnosis: (Mark all that
apply)
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
P21
During the past six months, did you refer any children for FASD assessment?
Yes
No
Page Break
Please feel free to comment on your response to any of the questions in this survey.
P22
Thank you for taking the time to answer these questions!
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AAP Pre-Training Evaluation Survey
Survey Path 2
Training: Treatment Across the Lifespan
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Treatment Across the Lifespan: Pre-…
Survey
Distributions
Data & Analysis
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Projects
Contacts
Library
Survey Director
Help
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Treatment Across the Lifespan: Pre-Training Evaluation Survey
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 your interest in fetal alcohol spectrum disorders (FASD). We would like to invite
you to complete a pre-training evaluation survey. We appreciate your willingness to help us
evaluate the effectivenss of the training and its impact on your practice as you address the
prevention, identification, and treatment of FASD.
This survey will take approximately 3 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 your 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 colletion of information is estimated to average 3 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 identifyer to help us match pre and post-training responses:
First 2 letters of your mother's
maiden name:
Month of your birthday:
Last 2 digits of your social
security number:
Page Break
https://uwmadison.co1.qualtrics.com/ControlPanel/?ClientAction=EditSurvey&Section=SV... 5/3/2017
Edit Survey | Qualtrics Survey Software
Page 2 of 3
State in which you practice. Use the drop down menu to find your State.
AL
Page Break
PK9
Which of the following approaches/care strategies is not applicable for children diagnosed
with an FASD? (Check all that apply)
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?
P10 c
Strongly
Disagree
Neither
Agree nor
Disagree Disagree
Agree
Strongly
Agree
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?
P15 e
Never
Rarely
Sometimes Usually
Always
a. Manage/coordinate the treatment of patient
Page Break
How confident are you in your skills to do the following? (Mark one response per row)
P17 d, e
Not at all A Little
Confident Confident Moderately Confident Com
in my
in my
Confident
in my
Co
Skills
Skills
in my Skills
Skills
in m
a. Utilize resources to refer patients for diagnosis
and/or treatment for FAS(D)
b. Manage/coordinate the treatment of persons with
FASDs
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Page 3 of 3
Page Break
How willing are you to do the following? (Mark one resonse per row)
P18 d, e
Not at
all
A little Moderately
Willing Willing
Willing
Completely
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
Please feel free to comment on your response to any of the questions in this survey.
P22
Thank you for taking the time to answer these questions!
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| File Type | application/pdf |
| Author | Melanie Chansky |
| File Modified | 2017-05-05 |
| File Created | 2017-05-05 |