Change Request Justification

Non-Substantive Change Request to OMB Control No. 0920-1129: Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships

Program Contact

Patricia Green

National Center on Birth Defects and Developmental Disabilities (NCBDDD)

1600 Clifton Rd, E-86

Atlanta GA 30333

Submission Date: June 30, 2017

Circumstances of Change Request for OMB 0920-1129

CDC requests approval for a non-substantive change to OMB Control No. 0920-1129: Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships.

Overall, these changes are being made to better align certain data collection instruments with the training strategies that are being implemented. Many of these training strategies were not finalized at the time of the original ICR request. Instruments are being changed to reduce burden on training participants, to provide Spanish-language versions, to accommodate website survey programming limitations, and to reflect changes in training platform design. Changes to each instrument are described in detail on the following pages.

Estimates of annualized burden hours for this change request decrease compared to the ICR that was previously approved. The revised burden estimate for the forms included in OMB Control No. 0920-1129 is 3,748 hours (compared to 3,764 in the approved ICR).

Description and Justification of Changes

1. AAP Pre-Training Evaluation Survey

Rationale for changing instrument: One of the Pediatric DSW “FASD Regional Education and Awareness Liaisons (REAL) Champions”, Dr. Maribel Campos, has the ability to present training sessions in her native Spanish language. She has presented several training modules in Puerto Rico in Spanish. After careful review of the resulting evaluation data and discussion with Dr. Campos, the DSW determined that to improve understandability and perhaps increase the validity of each evaluation instrument, it would be beneficial to provide the instruments in Spanish for Spanish language speakers. Therefore, we have translated each of our evaluation instruments into Spanish. This translation has not changed the time burden to complete the instrument.

Table 1. Comparison of current AAP Pre-Training Evaluation Survey with requested changes

Current Wording	Requested Changes
The instructions and all questions included in the pre-training evaluation instrument.	The instructions and all questions included in the pre-training evaluation instrument are now presented in Spanish.

2. AAP Post-Training Evaluation Survey

Rationale for changing instrument: One of the Pediatric DSW “FASD Regional Education and Awareness Liaisons (REAL) Champions”, Dr. Maribel Campos, has the ability to present training sessions in her native Spanish language. She has presented several training modules in Puerto Rico in Spanish. After careful review of the resulting evaluation data and discussion with Dr. Campos, the DSW determined that to improve understandability and perhaps increase the validity of each evaluation instrument, it would be beneficial to provide the instruments in Spanish for Spanish language speakers. Therefore, we have translated each of our evaluation instruments into Spanish. This translation has not changed the time burden to complete the instrument.

Table 2. Comparison of current AAP Post-Training Evaluation Survey with requested changes

Current Wording	Requested Changes
The instructions and all questions included in the post-training evaluation instrument.	The instructions and all questions included in the post-training evaluation instrument are now presented in Spanish.

3. AAP Three-Month Follow-up Evaluation Survey

Rationale for changing instrument: One of the Pediatric DSW “FASD Regional Education and Awareness Liaisons (REAL) Champions”, Dr. Maribel Campos, has the ability to present training sessions in her native Spanish language. She has presented several training modules in Puerto Rico in Spanish. After careful review of the resulting evaluation data and discussion with Dr. Campos, the DSW determined that to improve understandability and perhaps increase the validity of each evaluation instrument, it would be beneficial to provide the instruments in Spanish for Spanish language speakers. Therefore, we have translated each of our evaluation instruments into Spanish. This translation has not changed the time burden to complete the instrument.

Table 3. Comparison of current AAP Three-Month Follow-Up Evaluation Survey with requested changes

Current Wording	Requested Changes
The instructions and all questions included in the three month post-training evaluation instrument.	The instructions and all questions included the three month post-training evaluation instrument are now presented in Spanish.

4. AAP Six-Month Follow-Up Evaluation Survey

Rationale for changing instrument: One of the Pediatric DSW “FASD Regional Education and Awareness Liaisons (REAL) Champions”, Dr. Maribel Campos, has the ability to present training sessions in her native Spanish language. She has presented several training modules in Puerto Rico in Spanish. After careful review of the resulting evaluation data and discussion with Dr. Campos, the DSW determined that to improve understandability and perhaps increase the validity of each evaluation instrument, it would be beneficial to provide the instruments in Spanish for Spanish language speakers. Therefore, we have translated each of our evaluation instruments into Spanish. This translation has not changed the time burden to complete the instrument.

Table 4. Comparison of current AAP Six-Month Follow-Up Evaluation Survey with requested changes

Current Wording	Requested Changes
The instructions and all questions included in the 6 month post-training follow-up evaluation instrument.	The instructions and all questions included in the 6 month post-training follow-up evaluation instrument are now presented in Spanish.

5. OB-GYN FASD-SBI Event Evaluation

Rationale for changing instrument: This survey was drafted with the intention of utilizing the survey for data collection of in-person training events only. However, the DSW would like to utilize the same evaluation questions for all DSW-generated online training modules. Questions were modified to account for a wide variety of audiences and to be useful for both in-person and online training. The fields below the title (Speaker, Event date, Event title) are only used in the paper version of the survey used in in-person trainings. Specific changes are described in bullets below, and language for requested changes to this survey (with comparison to previously-approved language) is included in Table 5. The changes have slightly reduced the time burden associated with the instrument, from 5 minutes to 4 minutes.

• Numbered each question. The questions in the prior survey were not numbered.

• Modified wording in the instructions.

• Modified wording in questions 1, 2, 3, 8, 9, 10, & 12.

• Deleted question “This training increased my awareness and knowledge of the harmful effects of alcohol on the developing fetus”.

Table 5. Comparison of current OB-GYN FASD-SBI Event Evaluation with requested changes

Current Wording	Requested Changes
We’re interested in your thoughts about this FASD training/ presentation.	We’re interested in your thoughts about this training/ presentation.
The speaker was knowledgeable about the content.	1. The speaker/training was knowledgeable about the content.
The speaker explained concepts clearly.	2. The speaker/training explained concepts clearly.
The presentation was presented in culturally competent, sensitive manner.	3. The training was presented in culturally competent, sensitive manner.
This training increased my awareness and knowledge of the harmful effects of alcohol on the developing fetus.	Deleted
I would attend another presentation on the topic.	8. I would attend/complete another training on the topic.
I would recommend this presentation to others.	9. I would recommend this training to others.
Overall, the training met or exceeded my expectations.	10. Overall, the training met my expectations.
How could this training be improved? (Was there information you would like that the training did not include? Is there a better way to present this information?)	12. How could this training be improved?

6. OB-GYN Avatar Training Satisfaction Survey

Rationale for changing instrument: The questions in the OMB-approved instrument were submitted prior to beta testing of the Alcohol Screening and Brief Intervention Training. Following significant feedback from trainees regarding user experience, the platform for the experiential brief encounter with a live standardized patient was moved to a videoconferencing online platform (Zoom), and additional changes were made to the training curriculum to augment learning of the steps to a brief encounter. Since the platform has changed significantly since the first version, the instrument’s questions are no longer applicable to the medium and experience. The questions were revised to best fit the needs for program evaluation of the newly re-designed training platform and content. Revisions to the instrument include changes in wording to more closely align with a live-teleconference encounter versus an avatar-assisted encounter. Specific changes are described in bullets below, and language for requested changes to this survey (with comparison to previously-approved language) is included in Table 6. These changes have slightly reduced the time burden of the instrument, from 5 minutes to 3 minutes.

• Change to the title from “Avatar Training Satisfaction Survey” to “Guided Brief Intervention Satisfaction Survey”

• Questions 1, 2, 3, 5, 6, 7, & 9 were deleted.

• Wording was modified in questions 4, 8, 10, & 12.

Table 6. Comparison of current OB-GYN Avatar Training Satisfaction Survey with requested changes

Current Wording	Requested Changes
Title : Avatar Training Satisfaction Survey	Revised Title: OB-GYN Guided Brief Intervention Satisfaction Survey
The avatars of me and my patient looked realistic enough	Deleted
The avatar’s movement and facial expressions looked natural	Deleted
It was just as easy to “talk” with the patient about substance use in virtual world via the avatar as it would be in real-world training.	Deleted
The avatar was distracting from the content of the conversation.	The animation was distracting from the content of the conversation.
I noticed a delay in response time while using the avatar in virtual world.	Deleted
The standardized patient was skillful and natural in the patient role.	Deleted
Feedback from the standardized patient/avatar was informative and useful to me.	Deleted
I prefer this training using the avatar in virtual world rather than real life role plays or simulations.	I prefer this training using the guided brief intervention rather than real life role plays or simulations.
Getting set up and started with this avatar training was easy enough.	Deleted
Avatar training is an expedient method for learning how to conduct a good intervention.	A guided brief intervention is a useful method for learning how to conduct an intervention.
12. Overall, the training met or exceeded my expectations.	Overall, the training met my expectations.

7. OB-GYN Telecom Training Satisfaction Survey

Rationale for changing instrument: The questions in the OMB-approved instrument were submitted prior to beta testing of the Alcohol Screening and Brief Intervention Training. Following significant feedback from trainees regarding user experience, the platform for the experiential brief encounter with a live standardized patient was moved to a videoconferencing online platform (Zoom), and additional changes were made to the training curriculum to augment learning of the steps to a brief encounter. Since the platform has changed significantly since the first version, the instrument’s questions are no longer applicable to the medium and experience. The questions were revised to best fit the needs for program evaluation of the newly re-designed training platform and content. Revisions to the instrument include changes in wording to more closely align with a live-teleconference encounter versus an avatar-assisted encounter. Specific changes are described in bullets below, and language for requested changes to this survey (with comparison to previously-approved language) is included in Table 7. These changes have reduced the time burden of the instrument, from 5 minutes to 3 minutes.

• Questions 2, 5, and 6 were deleted.

• Wording was modified in questions 3, 7 & 8.

Table 7. Comparison of current OB-GYN Telecom Training Satisfaction Survey with requested changes

Current Wording	Requested Changes
2. Experiencing the standardized patient’s voice and facial expressions were helpful in this interaction.	Deleted
3. It was just as easy to talk with the patient about substance use in this interactive environment as it would be in real-world training.	It was just as easy to talk with the patient about substance use via teleconference as it would be in in-person training.
5. I noticed a delay in response time while using this method of communicating.	Deleted
6. The standardized patient was skillful and natural in the patient role.	Deleted
7. Feedback from the standardized patient was informative and useful to me.	Feedback from the standardized patient was useful to me.
8. I prefer this method of training to real life role plays or simulations.	I prefer this method of training to in-person role plays or simulations.

8. NOFAS Post-Test Survey

Rationale for changing instrument: The OBGYN Discipline-Specific Workgroup (DSW) has created several trainings that the DSW would like to evaluate. An existing OMB-approved instrument will meet the evaluation needs for these trainings, but to meet the needs of trainees (practicing OBGYNs), skip logic is being implemented to ensure that trainees only see questions that are relevant to them. In the case of in-person trainings, the survey has also been shortened to increase the likelihood that trainees will complete it. Specific changes are described in bullets below, and language for requested changes to this survey (with comparison to previously-approved language) is included in Table 8. These changes have not changed the time burden for the instrument.

• This survey would have three designated paths according to the type of training (in-person vs. online) implemented by using skip-logic.

  • Path 1, in-person training: Users would answer questions 1-4.

  • Path 2, DSW Developed online Role of the OB-GYN in the Prevention of FASD: Users would answer all questions.

  • Path 3: DSW developed online Alcohol SBI Training: Users would answer questions 5a, 5b, 5c, 7b, 7c, 7d, 7e, and 7i.

• Changed title of instrument to FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation

• Removed NOFAS from instructions

• Eliminated questions 5g, 6, 7g, 7h, 7j, 9, & 10.

• Modified wording in 7i

Table 8. Comparison of current NOFAS Post-Test Survey with requested changes

Current Wording	Requested Changes
Title: “NOFAS Post-Test”	Revised title: “FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation”
Thank you for completing this survey. You are helping NOFAS to improve and identify the needs of healthcare providers in preventing and identifying fetal alcohol spectrum disorders.	Thank you for completing this survey. You are helping us to improve and identify the needs of healthcare providers in preventing and identifying fetal alcohol spectrum disorders.
5g. Diagnosis of one of the FASDs may confer a stigma to a child and/or his or her family	Deleted
6. In your current position, do you provide services to individuals who may have an FASD? Yes No Not Sure Probably but individual is not diagnosed	Deleted
7g. Identifying persons who may have one of the FASDs	Deleted
7h. Diagnosing persons who may have one of the FASDs	Deleted
7i. Referring patients/clients for diagnosis and/or treatment services for an FASD or alcohol use disorder	Referring patients/clients for diagnosis and/or treatment services for alcohol use disorder
7j. Managing/coordinating the treatment and care of persons who have one of the FASDs	Deleted
9. What additional information or resources do you need to make changes in your practice related to the prevention, identification, and treatment of for your patients who have or may have one of the FASDs?	Deleted
10. I have an increased understanding of fetal alcohol spectrum disorders (FASDs) after the training.  Yes  No  Not sure	Deleted

9. NOFAS Pre-Test Survey

Rationale for changing instrument: The OBGYN Discipline-Specific Workgroup (DSW) has created several trainings that the DSW would like to evaluate. An existing OMB-approved instrument will meet the evaluation needs for these trainings, but to meet the needs of trainees (practicing OBGYNs), skip logic is being implemented to ensure that trainees only see questions that are relevant to them. In the case of in-person trainings, the survey has also been shortened to increase the likelihood that trainees will complete it. Specific changes are described in bullets below, and language for requested changes to this survey (with comparison to previously-approved language) is included in Table 9. These changes have not changed the time burden for the instrument.

• This survey would have three designated paths according to the type of training (in-person vs. online) implemented by using skip-logic.

  • Path 1, in-person training: Users would answer questions 1-5.

  • Path 2, DSW Developed online Role of the OB-GYN in the Prevention of FASD: Users would answer all questions

  • Path 3: DSW developed online Alcohol SBI Training: Users would answer questions 6a, 6b, 6c, 7b, 7c, 7d, 7e, and 7i.

• Changed title of instrument to FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation

• Removed NOFAS from instructions

• Eliminated questions 6g, 7g, 7h, 7j

• Modified wording in 7i

Table 9. Comparison of current NOFAS Pre-Test Survey with requested changes

Current Wording	Requested Changes
Title: “NOFAS Pre-Test”	Revised title: “FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation”
Thank you for completing this survey. You are helping NOFAS to improve and identify the needs of healthcare providers in preventing and identifying fetal alcohol spectrum disorders.	Thank you for completing this survey. You are helping us to improve and identify the needs of healthcare providers in preventing and identifying fetal alcohol spectrum disorders.
6g. Diagnosis of one of the FASDs may confer a stigma to a child and/or his or her family	Deleted
7g. Identifying persons who may have one of the FASDs	Deleted
7h. Diagnosing persons who may have one of the FASDs	Deleted
7i. Referring patients/clients for diagnosis and/or treatment services for an FASD or alcohol use disorder	Referring patients/clients for diagnosis and/or treatment services for alcohol use disorder
7j. Managing/coordinating the treatment and care of persons who have one of the FASDs	Deleted

10. FASD Core Training Survey – Pre-Test

Rationale for changing instrument: Since originally developing this instrument, we have learned several things about the limitations of the website where it will be hosted. Given those limitations, we made several edits to simplify the survey, such as by removing open-ended responses and limiting the number of skips used. (However, some skips are in place to reduce the burden on respondents.) Other changes include editing response options to better reflect the responses that a respondent may select or to reduce the number of words. Specific changes are described in bullets below, and language for requested changes to this survey (with comparison to previously-approved language) is included in Table 10. These changes have not changed the time burden for the instrument.

• This survey would have three designated paths depending on the training course taken. These paths are implemented by using skip-logic:

  • Path 1: Alcohol SBI Training or Role of the OBGYN Training: Users would answer questions 1-3, 11-14, 23-24, 27-32.

  • Path 2: Referral to Treatment Training: Users would answer questions 1-3, 11-18, 23-24, 27-32.

  • Path 3: All other training courses: Users would answer all questions.

• Response options were edited in questions 1, 12, 14, 16, and 22.

• The phrase “If you selected ‘a professional organization’ in Question 1” was added to the beginning of questions 2 and 3 in order to remove a skip.

• Questions 19 and 20 were edited to increase the focus on inquiring about prenatal exposure to alcohol and referring patients for diagnosis/treatment.

• Questions 24 and 28 were both split into two parts in order to facilitate survey programming

• Question 30 was changed from a select all that apply question to an open-ended question.

Table 10. Comparison of current FASD Core Training Survey – Pre-Test with requested changes

Current Wording			Requested Changes
1. I found out about this training from: (Check all that apply.) A professional organization…………>CONTINUE TO Q2 A recognized leader in my field……..>GO TO Q4 A colleague at my practice setting….>GO TO Q4 Other, please specify __________________....>GO TO Q4			1. I found out about this training from: (Check all that apply.) A professional organization A recognized leader in my field A colleague at my practice/healthcare setting My academic program A previous trainee CDC Other
2. Please provide name of the professional organization from which you found out about this training ______________________			2. If you selected “a professional organization” in Question 1, please provide name of the professional organization from which you found out about this training ______________________
3. How did you find out about this training from the professional organization? (Check all that apply.) Website Email At a conference Other, please specify __________________			3. If you selected “a professional organization” in Question 1, how did you find out about this training from the professional organization? (Check all that apply.) Website Email At a conference Other, please specify __________________
12. When do you (or someone in your practice) ask your patients/clients or their parents/caregivers about their alcohol use? (Check only one response.) Never Annually At each visit When indicated (please describe: ____________________) Other, please specify____________			12. When do you (or someone in your practice) ask your patients/clients or their parents/caregivers about their alcohol use? (Check only one response.) Never Annually At each visit When indicated (please describe: ____________________)
14. What does initial patient/client screening for alcohol use consist of in your practice setting? (Check only one response.) Informal questions (Do you drink? How often/much do you drink?, etc.). Formal screening tool or evidence-based/ validated screening instrument (AUDIT, AUDIT-C, DAST, CAGE, CRAFFT, NIAAA Youth Alcohol Screen, etc.). I don't know.			14. What does initial patient/client screening for alcohol use consist of in your practice setting? (Check only one response.) Informal questions (Do you drink? How often/much do you drink?, etc.). Formal screening tool or evidence-based/ validated screening instrument (AUDIT, AUDIT-C, DAST, CAGE, CRAFFT, NIAAA Youth Alcohol Screen, etc.). My practice does not screen. I do not work with patients. I don't know.
16. Is screening for alcohol use followed by some type of intervention in your practice setting? (Check all that apply.) No, there is no patient/client education or intervention done following the initial screening…….>GO TO Q19 Yes, all patients/clients are given educational materials/information on “safe” levels of alcohol and health risks associated with consuming too much alcohol ....> CONTINUE TO Q17 Yes, patients/clients who screen positive for risky alcohol use are asked follow-up questions and provided brief counseling. …….....> CONTINUE TO Q17 Yes, patients/clients who screen positive for risky alcohol use are asked follow-up questions and provided with additional resources (e.g., a list of treatment and/or counseling services in the community). .…….....> CONTINUE TO Q17 Not sure if there is an intervention following the initial screening. …….GO TO Q19			16. Is screening for alcohol use followed by some type of intervention in your practice setting? (Check all that apply.) Yes, all patients/clients are given educational materials/information on health risks associated with alcohol ....> CONTINUE TO Q17 Yes, patients/clients who screen positive for risky alcohol use are provided brief counseling. …….....> CONTINUE TO Q17 Yes, patients/clients who screen positive for risky alcohol use are provided with referrals for treatment and/or counseling services. .…….....> CONTINUE TO Q17 No, there is no patient/client education or intervention done following the initial screening…….>GO TO Q19 Not sure if there is an intervention following the initial screening. …….>GO TO Q19 N/A – my practice does not screen/I do not work with patients….>GO TO Q19
19. In your current position, do you provide services to individuals who may have fetal alcohol spectrum disorders (FASDs)? (Check only one response.) Yes No Not sure			19. How often does your practice typically inquire about prenatal exposure to alcohol for a pediatric patient? (Check only one response.) Always Usually Sometimes Rarely Never N/A – I do not work with pediatric patients
20. On a scale from 1 to 5 where 1 means you strongly disagree with the statement and 5 means you strongly agree, to what extent do you disagree or agree with the following statements. (Select one number per row). (See Table 12 below for Q20 original sub-questions and response categories. Note that this request removes this table from the instrument and replaces it with the question in the column to the right.)			20. How often does your practice identify and refer pediatric patients for FASD diagnosis and/or treatment services? (Check only one response.) Always Usually Sometimes Rarely Never N/A – I do not work with pediatric patients
22. (Response options only) Not confident in my skills Slightly confident in my skills Moderately confident in my skills Very confident in my skills Totally confident in my skills			22. (Response options only) 1: Not confident in my skills 2: Slightly confident in my skills 3: Moderately confident in my skills 4: Very confident in my skills 5: Totally confident in my skills
24. Please check the response that best represents your current position: PHYSICIAN OB/GYN Geneticist Pediatrician/pediatric sub-specialist Psychiatrist Family Physician Internist Preventive Medicine Occupational Medicine Addiction Medicine Physician, other, please specify ____________ OTHER MEDICAL Dentist Physician Assistant Medical Assistant Nurse (NP, RN, LPN) Other Medical, please specify _____________ ALLIED HEALTH Psychologist (unspecified) Rehabilitation Psychologist Clinical Psychologist Community Psychologist Counselor (including AODA Counselor) Social worker OT/PT/SLP Medical Technologist Other allied health professional, please specify______ OTHER Public Health Specialist Special Educator Other Educator Administrator Corrections Lawyer/Judge Scientist Prevention Specialist Other, please specify ______________			24a. Please check the response that best represents your current position: Physician Other Medical Allied Health Other
None (formerly part of Q24)			24b. PHYSICIAN OB/GYN Geneticist Pediatrician/pediatric sub-specialist Psychiatrist Family Physician Internist Preventive Medicine Occupational Medicine Addiction Medicine Physician, other, please specify ____________ OTHER MEDICAL Dentist Physician Assistant Medical Assistant Nurse (NP, RN, LPN) Other Medical, please specify _____________ ALLIED HEALTH Psychologist (unspecified) Rehabilitation Psychologist Clinical Psychologist Community Psychologist Counselor (including AODA Counselor) Social worker OT/PT/SLP Medical Technologist Other allied health professional, please specify______ OTHER Public Health Specialist Special Educator Other Educator Administrator Corrections Lawyer/Judge Scientist Prevention Specialist Other, please specify ______________
28. Please tell us about yourself. (Check all that apply.) MEDICAL AND NURSING STUDENTS Med 1 Med 2 Med 3 Med 4 Clerkship Preceptorship Nursing Dental Medical Assistant ALLIED HEALTH STUDENTS Allied Health (e.g., OT/PT SLP/Social Work, Counseling, etc.) OTHER STUDENT Pre-doctoral student Graduate Student Undergraduate Student Other, please specify _______			28a. Please tell us about yourself. Medical and Nursing Students Allied Health Students (e.g., OT/PT SLP/Social Work, Counseling, etc.) Other Student
None (formerly part of Q28)			28b. MEDICAL AND NURSING STUDENTS Med 1 Med 2 Med 3 Med 4 Clerkship Preceptorship Nursing Dental Medical Assistant OTHER STUDENT Pre-doctoral student Graduate Student Undergraduate Student Other, please specify _______
30. In which State(s) do you provide services or go to school?			30. In which State(s) do you provide services or go to school?
 AL  AK  AZ  AR  CA  CO  CT  DE  DC  FL  FM  GA  GU  HI  ID  IL  IN  IA  KS  KY	 LA  ME  MD  MA  MH  MI  MN  MP  MS  MO  MT  NE  NV  NH  NJ  NM  NY  NC  ND  OH	 OK  OR  PA  PR  PW  RI  SC  SD  TN  TX  UT  VT  VI  VA  WA  WV  WI  WY  Not applicable	(responses are now open-ended)

Table 12. Q20 Original Sub-Questions and Response Categories

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
It is important to routinely screen all patients/clients for alcohol use	1	2	3	4	5
Screening a person for alcohol use confers a stigma to the person being screened	1	2	3	4	5
It is important to screen all pregnant women for alcohol use	1	2	3	4	5
It is important to screen all women of reproductive age for alcohol use	1	2	3	4	5
It is important to educate women of reproductive age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
It is important to inquire about and document potential prenatal exposure for all pediatric patients	1	2	3	4	5
Diagnosis of one of the FASDs may confer a stigma to a child and/or his or her family	1	2	3	4	5

Estimates of Annualized Burden hours (decrease from approved ICR)

Estimates of annualized burden hours for this change request have slightly decreased from the approved ICR. The revised burden estimate for the forms included in OMB Control No. 0920-1129 is 3,748 (compared to the approved burden estimate of 3,764).

Instruments included in this request are highlighted in the table below.

Table 1. Estimated Annualized Burden Hours

Type of Respondents	DSW/ Organization	Form Name	No. of Respondents	No. Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours
Project Grantee Staff	Westat (Cross-Site Evaluator)	DSW Report	90	2	10/60	30
Project Grantee Staff	Westat (Cross-Site Evaluator)	High Impact Study: Discipline Specific Workgroup Discussion Guide for Project Staff	10	2	60/60	20
Health Care System Staff	Westat (Cross-Site Evaluator)	High Impact Study: Key Informant Interview - Health Care System Staff	10	2	60/60	20
FASD Core Training Participants	Westat (Cross-Site Evaluator)	FASD Core Training Survey – Pre-Test	4013	1	9/60	602
FASD Core Training Participants	Westat (Cross-Site Evaluator)	FASD Core Training Survey – Post-Test	4013	1	5/60	334
FASD Core Training Participants	Westat (Cross-Site Evaluator)	FASD Core Training Survey – 6 Month Follow-Up	4013	1	6/60	401
Nurses	Nursing	Pre-Training Survey for Nursing	667	1	9/60	100
Nurses	Nursing	Post-Training Survey for Nursing	550	1	9/60	83
Nurses	Nursing	Six Month Follow-Up Training Survey for Nursing	440	1	9/60	66
Nurses	Nursing	Nursing DSW Polling Questions	417	1	5/60	35
Nurses	Nursing	Key Informant Interviews with Champions	14	2	45/60	21
Nurses	Nursing	Brief Questionnaire for Nursing Organization Memberships	2934	1	10/60	489
Nurses	Nursing	Friends & Members of the Network Survey	34	2	10/60	11
Healthcare Organization Representatives	Nursing	Healthcare Organization Utilization Survey	234	1	30/60	117
Obstetrician-Gynecologists and students in allied health professions	OBGYN	OBGYN SBI Knowledge & Agency	600	1	2/60	20
Obstetrician-Gynecologists	OBGYN	OBGYN BI-MI Proficiency Rating Scale - Provider Skills Training Baseline	600	1	3/60	30
Students in allied health professions	OBGYN	OBGYN BI-MI Proficiency Rating Scale - Standardized Patient Version	600	1	3/60	30
Obstetrician-Gynecologists	OBGYN	OBGYN BI-MI Proficiency Rating Scale - Provider Follow Up (3m & 6m)	600	2	3/60	60
Obstetrician-Gynecologists and students in allied health professions	OBGYN	OBGYN Telecom Training Satisfaction Survey	480	1	3/60	24
Obstetrician-Gynecologists and students in allied health professions	OBGYN	OBGYN Avatar Training Satisfaction Survey (New title: OBGYN Guided Brief Intervention Satisfaction Survey	120	1	3/60	6
Obstetrician-Gynecologists	OBGYN	OBGYN FASD-SBI Training Event Evaluation	124	1	4/60	8
Residency Directors, Training Coordinators, Clinical Directors, Obstetrician-Gynecologists	OBGYN	OBGYN Qualitative Key Informant Interview - Pre-Training	34	1	25/60	14
Residency Directors, Training Coordinators, Clinical Directors, Obstetrician-Gynecologists	OBGYN	OBGYN Qualitative Key Informant Interview - Post-Training	34	1	25/60	14
Certified Medical Assistants and students	Medical Assistants	Medical Assistant – Pre-Test Survey	334	1	10/60	56
Students in allied health professions	Medical Assistants	Medical Assistant – Pre-Test Survey (Academic)	67	1	10/60	12
Certified Medical Assistants and students	Medical Assistants	Medical Assistant – Post-Test Survey	334	1	10/60	56
Students in allied health professions	Medical Assistants	Medical Assistant – Post-Test Survey (Academic)	67	1	10/60	11
Certified Medical Assistants and students	Medical Assistants	Medical Assistant Follow Up Survey	200	1	10/60	33
Students in allied health professions	Medical Assistants	Medical Assistant Follow Up Survey (Academic)	17	1	10/60	3
Certified Medical Assistants and students	Medical Assistants	Medical Assistants Change in Practice Survey	250	1	15/60	63
Pediatricians	Pediatrics	Survey of Pediatricians - Baseline and Follow Up	534	2	10/60	178
Pediatricians	Pediatrics	AAP Post-Training Evaluation Survey (English & Spanish versions)	120	1	5/60	10
Pediatricians	Pediatrics	AAP Pre-Training Evaluation Survey (English & Spanish versions)	120	1	3/60	6
Pediatricians	Pediatrics	AAP Three Month Follow Up Evaluation Survey (English & Spanish versions)	120	1	2/60	4
Pediatricians	Pediatrics	AAP Six Month Follow Up Evaluation Survey (English & Spanish versions)	120	1	5/60	10
Pediatricians	Pediatrics	FASD Toolkit User Survey	50	1	15/60	13
Pediatricians	Pediatrics	FASD Toolkit Evaluation Focus Group/Guided Interview	10	1	30/60	5
Pediatricians	Pediatrics	Pediatric FASD Regional Education and Awareness Liaisons Work Plan	10	1	20/60	3
Pediatricians	Pediatrics	Pediatric FASD Regional Liaison/Champion Training Session Evaluation	10	1	4/60	1
Family Medicine Physicians	Social Work and Family Medicine	Family Medicine Evaluation Questions Addendum for Practice or Individual Provider	62	1	8/60	8
Family medicine physicians, social workers, social work students	Social Work and Family Medicine	Social Work and Family Physicians Pre-training Survey	1167	1	8/60	156
Family medicine physicians, social workers, social work students	Social Work and Family Medicine	Social Work and Family Physicians Post-training Survey	1167	1	5/60	97
Family medicine physicians, social workers, social work students	Social Work and Family Medicine	Social Work and Family Physicians 6-Month Follow Up Survey	1167	1	8/60	156
NOFAS webinar attendees	NOFAS	NOFAS Webinar Survey	601	1	2/60	20
NOFAS webinar attendees	NOFAS	NOFAS Three Month Follow-Up Webinar Questionnaire	601	1	2/60	20
NOFAS training participants	NOFAS	NOFAS Pre-Test Survey (New title: FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation)	551	1	3/60	28
NOFAS training participants	NOFAS	NOFAS Post-Test Survey (New title: FASD Prevention, Identification, & Alcohol Screening Post-Training Evaluation)	551	1	3/60	28
Systems change project participants	Cross-DSW	Clinical Process Improvement Survey	246	2	10/60	82
Systems change project participants	Cross-DSW	TCU Organizational Readiness Survey	246	2	10/60	82
Systems change project participants	Cross-DSW	Organizational Readiness to Change Assessment	220	2	10/60	73
TOTAL			29,573			3748

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