Nursing DSW Polling - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Nursing DSW

Polling Questions for SBI and Implementation

1. How familiar are you with the CDC’s “Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use” guide?

   1. I’ve used the guide.

   2. I’ve seen or read the guide, but not used it.

   3. I’ve heard of the guide, but not read or used it.

   4. I’m not at all familiar with the guide.

2. In a typical work day, how many clients or patients do you see? _____

3. In a typical work day, how many female patients of reproductive age do you see? _____
   
   

4. Have you received any prior training related to conducting alcohol screening and brief intervention?

   1. Yes, I’ve participated in one or more formal training workshops or courses.

   2. Yes, I’ve received informal training.

   3. No, I’ve not received prior training.

5. How knowledgeable are you about alcohol screening and brief intervention?

   1. Novice

   2. Beginner

   3. Competent

   4. Proficient

   5. Expert

6. With which patient groups are you likely to conduct alcohol screening and brief intervention? (Check all that apply.)
   ____ Adolescent males
   ____ Adolescent females

____ Females of reproductive age

____ Males

____ Older adults

____ None of the above

7. What is your primary work role?

   1. Executive/Administrator

   2. Quality Assurance/Training

   3. Clinical Supervisor

   4. Clinical/Direct Patient Care (medical)

   5. Clinical/Direct Patient Care (behavioral health)

   6. Other

8. Does your organization have co-located behavioral health? Yes No

9. Which of the following may be barriers to implementing alcohol SBI at your organization? (Check all that apply)

   1. EHR

   2. Billing/Reimbursement

   3. Management buy-in

   4. Clinician buy-in

   5. Patient resistance

   6. No barriers

10. What other barriers exist to implementing alcohol SBI at your organization?

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS

D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).