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pdfThis document contain screenshots for the AAP Post-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. Post-Training Survey Path 1 (Training: Screening, Assessment, and Diagnosis)
2. Post-Training Survey Path 2 (Training: ND-PAE)
3. Post-Training Survey Path 3 (Training: Treatment Across the Lifespan)
AAP Post-Training Evaluation Survey
Survey Path 1
Training: Screening, Assessment, and Diagnosis
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Peds DSW Post-Training Evaluation…
Survey
Distributions
Data & Analysis
Page 1 of 8
Projects
Contacts
Library
Survey Director
Help
Reports
Peds DSW Post-Training Evaluation Survery - 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
Block Options
Form Approved
OMB No. 0920-1129
Exp. Date 08/31/2019
Thank you for competing the training on fetal alcohol spectrum disorders (FASD). 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 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 identifying information will be included. Risks to participating in
this survey are minimal and include the risk of you information becoming known to individuals
outside the AAP.
Your participation in this survey 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 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 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 pre- and post-training 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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Page 2 of 8
AL
Page Break
How would you rate your overall satisfaction with this course?
PO5
Not at all Satisfied
A little Satisfied
Moderately Satisfied
Satisfied
Completely Satisfied
Somewhat Exceeded
Exceeded
Page Break
How well did this course meet your educational needs?
PO6
Not at all Met
Slightly Met
Met
Page Break
Will you recommend this course to your colleagues?
PO7 yes=1
no=2
Yes (Why?)
No (Why not?)
Please offer suggestions for improvement:
POS8
Page Break
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Page 3 of 8
Neither
Agree nor
Strongly
Disagree
Disagree
Disagree
Strongly
Agree
Agree
Describe the diagnostic criteria and
approaches for diagnosis for each
condition along the continuum of
FASDs, including ARND, ND-PAE,
FAS, pFAS, and ARBD.
Distinguish major physical and
neurobehavioral features for
differential diagnosis of FASDs from
other genetic and behavioral
disorders as well as relevant
comorbidities.
Explain the importance of screening
every patient for a history of
prenatal alcohol exposure at birth
and during their first clinic visit.
Page Break
POK11
Which of the following are the primary facial dysmorphic features associated with fetal
alcohol syndrome? (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
POK12
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
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Page 4 of 8
not applicable for children diagnosed
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 statements? (Mark one response per row)
PO15 c, d
Strongly
Neither
Agree
nor
Disagree Disagree Disagree Agre
Diagnosis of one of the FASDs may confer a negative stigma to a
child and/or his or her family
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?
PO16
PO17 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
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Page 5 of 8
Alcohol consumption during pregnancy...
Neither
Agree
Strongly
nor
Strongly
Disagree Disagree Disagree Agree Agree
Is more prevalent in women with higher incomes
Is more prevalent in women with higher levels of
education
Does not vary between ethnic or racial groups
Page Break
How confident are you in your skills to do the following? (Mark one response per row)
PO19 a, b,
c
Not at all A Little
Confident Confident Moderately Confident Co
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)
Q19
Not at
all
A little Moderately
Completel
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 disorders
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
Page Break
PO21 yes=1
no=2
As a result of participating in this learning activity, do you intend to make change in your
practice?
Yes
No
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Page 6 of 8
Page Break
PO22
Do you feel a commercial product, device, or service was inappropriately promoted in the
educational content?
yes=1 no=2
Yes (please comment)
No
PO23
Please feel free to comment on your response to any of the questions in this survey or provide
any feedback.
Page Break
Please Take a Moment to Tell Us About Yourself.
Are You... (select one)
1. Male
2. Female
3. Transgender
Page Break
With what racial or cultural group(s) do you identify yourself? (Mark all that apply)
White, non-Hispanic/Latin@
Hispanic/Latin@
Black/African American, non-Hispanic/Latin@
Asian
Native Hawaiian or other Pacific Islander
American Indian/Alaska Native
Other (Specify)
P
B
k
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What year did you complete or will you complete your training:
Page 7 of 8
Are you, or will you be a:
Primary care pediatrician
Developmental/behavioral pediatrician
Geneticist
Other pediatric sub-specialty (Specify)
Family Physician
Other (Specify)
Page Break
Please indicate your primary employment site setting, that is, the setting where you spend
most of your time. Mark only ONE response.
Self-employed solo practice
Two physician practice
Pediatric group practice, 3-10 pediatricians
Pediatric group practice, >10 pediatricians
Multispecialty group practice
Health maintenance organization (staff model)
Medical school or parent university
Non-profit community health center
Non-government hospital or clinic
City/county/state government hospital or clinic
US government hospital or clinic
Other (Specify)
Page Break
Please describe the community in which your primary practice/position is located?
Urban, inner city
Urban, not inner city
Suburban
Rural
Thank you for taking the time to answer this survey!
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Page 8 of 8
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AAP Post-Training Evaluation Survey
Survey Path 2
Training: ND-PAE
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Page 1 of 7
Peds DSW Post-Training Evaluation…
Survey
Distributions
Data & Analysis
Projects
Contacts
Library
Survey Director
Help
Reports
Peds DSW Post-Training Evaluation Survery - 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 competing the training on fetal alcohol spectrum disorders (FASD). 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 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 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 in this survey 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 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 pre- and post-training 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
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Page 2 of 7
Page Break
How would you rate your overall satisfaction with this course?
PO5
Not at all Satisfied
A little Satisfied
Moderately Satisfied
Satisfied
Completely Satisfied
Somewhat Exceeded
Exceeded
Page Break
How well did this course meet your educational needs?
PO6
Not at all Met
Slightly Met
Met
Page Break
Will you recommend this course to your colleagues?
PO7 yes=1
no=2
Yes (Why?)
No (Why not?)
Please offer suggestions for improvement:
POS8
Page Break
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PO9 n, q
Page 3 of 7
To what extent do you agree the following educational objectives were met? (Mark one
response per row)
Neither
Agree nor
Strongly
Disagree
Disagree
Disagree
Strongly
Agree
Agree
a. Explain the importance of
screening every patient for a history
of prenatal alcohol exposure at birth
and during their first clinic visit.
b. Name the 4 diagnostic criteria for
ND-PAE.
Page Break
POK11
Which of the following are the primary facial dysmorphic features associated with fetal
alcohol syndrome? (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
POK12
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
POK14
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.
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Page 4 of 7
Page Break
To what extent do you agree with the following statements? (Mark one response per row)
PO15 c, d
Neither
Agree
Strongly
nor
Disagree Disagree Disagree Agre
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?
PO16
PO17 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
PO18 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...
Strongly
Neither
Agree
nor
Disagree Disagree Disagree Agree
Strongly
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 5 of 7
How confident are you in your skills to do the following? (Mark one response per row)
PO19 a, b,
c
Not at all
A Little
Confident Confident Moderately Confident Co
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)
PO20 a, b,
c
Not at
all
A little Moderately
Completel
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 disorders
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
Page Break
PO21 yes=1
no=2
PO21 text
As a result of participating in this learning activity, do you intend to make change in your
practice?
Yes
No
If yes, describe what you will do differently in practice and how you will accomplish this
change.
Page Break
PO22
yes=1 no=2
Do you feel a commercial product, device, or service was inappropriately promoted in the
educational content?
Yes (please comment)
No
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PO23
Page 6 of 7
Please feel free to comment on your response to any of the questions in this survey or provide
any feedback.
Page Break
Please Take a Moment to Tell Us About Yourself.
Are You... (select one)
1. Male
2. Female
3. Transgender
Page Break
With what racial or cultural group(s) do you identify yourself? (Mark all that apply)
White, non-Hispanic/Latin@
Hispanic/Latin@
Black/African American, non-Hispanic/Latin@
Asian
Native Hawaiian or other Pacific Islander
American Indian/Alaska Native
Other (Specify)
Page Break
What year did you complete or will you complete your training:
Are you, or will you be a:
Primary care pediatrician
Developmental/Behavioral pediatrician
Geneticist
Other Pediatric Sub-specialty (Specify)
Family Physician
Other (Specify)
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Page 7 of 7
Page Break
Please indicate your primary employment site setting, that is, the setting where you spend
most of your time. Mark only ONE response.
Self-employed solo practice
Two physician practice
Pediatric group practice, 3-10 pediatricians
Pediatric group practice, >10 pediatricians
Multispecialty group practice
Health maintenance organization (staff model)
Medical school or parent university
Non-profit community health center
Non-government hospital or clinic
City/county/state government hospital or clinic
US government hospital or clinic
Other (Specify)
Page Break
Please describe the community in which your primary practice/position is located?
Urban, inner city
Urban, not inner city
Suburban
Rural
Thank you for taking the time to answer this survey!
Add Block
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AAP Post-Training Evaluation Survey
Survey Path 3
Training: Treatment Across the Lifespan
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Page 1 of 6
Treatment Across the Lifespan: Post…
Survey
Distributions
Data & Analysis
Projects
Contacts
Library
Survey Director
Help
Reports
Treatment Across the Lifespan: Post-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 competing the training on fetal alcohol spectrum disorders (FASD). 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 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 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 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 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 pre- and post-training 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
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Page 2 of 6
How would you rate your overall satisfaction with this course?
PO5
Not at all Satisfied
A little Satisfied
Moderately Satisfied
Satisfied
Completely Satisfied
Somewhat Exceeded
Exceeded
Page Break
How well did this course meet your educational needs?
PO6
Not at all Met
Slightly Met
Met
Page Break
Will you recommend this course to your colleagues?
PO7 yes=1
no=2
Yes (Why?)
No (Why not?)
Please offer suggestions for improvement:
POS8
Page Break
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QO9 j, k, l,
m
To what extent do you agree the following educational objectives were met? (Mark one
response per row)
Page 3 of 6
Neither
Agree nor
Strongly
Disagree
Disagree
Disagree
Strongly
Agree
Agree
a. Identify potential referrals,
secondary conditions, risk factors,
and care planning for individuals
with FASDs.
b. Describe the developmental and
functional concerns for individuals
with FASDs and their families across
the lifespan.
c. Explain various treatment
approaches for FASDs.
d. Explain support services and
resources for families and providers.
Page Break
POK14
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?
PO15 c
Strongly
Neither
Agree
nor
Disagree Disagree Disagree Agre
a. Diagnosis of one of the FASDs may confer a negative stigma to a
child and/or his or her family
Page Break
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Page 4 of 6
How confident are you in your skills to do the following? (Mark one response per row)
PO19 d, e
Not at all
A Little
Confident Confident Moderately Confident Co
in my
in my
Confident
in my
C
Skills
Skills
in my Skills
Skills
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
How willing are you to do the following? (Mark one response per row)
PO20 d, e
Not at
all
A little Moderately
Willing Willing
Willing
Completel
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
PO21 yes=1
no=2
PO21 text
As a result of participating in this learning activity, do you intend to make change in your
practice?
Yes
No
If yes, describe what you will do differently in practice and how you will accomplish this
change.
Page Break
PO22
Do you feel a commercial product, device, or service was inappropriately promoted in the
educational content?
Yes (please comment)
No
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PO23
Page 5 of 6
Please feel free to comment on your response to any of the questions in this survey or provide
any feedback.
Page Break
Please take a moment to tell us about yourself.
Are you (Circle one):
1. Male
2. Female
3. Transgender
Page Break
With what racial or cultural group(s) do you identify yourself? (Mark all that apply)
White, non-Hispanic/Latin@
Hispanic/Latin@
Black/African American, non-Hispanic/Latin@
Asian
Native Hawaiian or other Pacific Islander
American Indian/Alaska Native
Page Break
What year did you complete or will you complete your training:
Are you, or will you be a:
Primary care pediatrician
Developmental/behavioral pediatrician
Geneticist
Other pediatric sub-specialty (Specify)
Family Physician
Other (Specify)
Page Break
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Page 6 of 6
Please indicate your primary employment site setting, that is, the setting where you spend
most of your time. Mark only ONE response.
Self-employed solo practice
Two physician practice
Pediatric group practice, 3-10 pediatricians
Pediatric group practice, >10 pediatricians
Multispecialty group practice
Health maintenance organization (staff model)
Medical school or parent university
Non-profit community health center
Non-government hospital or clinic
City/county/state government hospital or clinic
US government hospital or clinic
Other (Specify)
Page Break
Please describe the community in which your primary practice/position is located?
Urban, inner city
Urban, not inner city
Suburban
Rural
Thank you for taking the time to answer this survey!
Add Block
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Legal
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| File Type | application/pdf |
| Author | Melanie Chansky |
| File Modified | 2017-05-05 |
| File Created | 2017-05-04 |