Brief Questionnaire for Nursing

Form Approved

OMB No. 0920-1129

Exp. Date 08/31/2019

Brief Questionnaire for Nursing Organization Memberships (Online)

You are invited to participate in this survey for members of nursing organizations. The purpose of the survey is to gather information about nurses’ practice behaviors related to FASD prevention and alcohol screening and brief intervention. Your participation is important in order to understand effects of the CDC FASD Project as well as to inform future activities of the Project.

This survey will take approximately 10 minutes to complete. Your participation is voluntary and responses will be kept secure. There are no costs associated with participating nor will you directly benefit from participation.

1. Are you currently in clinical practice?

Yes

No

2. How often do you talk to your patients about their alcohol use?

Never

Occasionally

About half the time

Frequently

Always

3. My practice has a protocol in place to screen all patients for their alcohol use.

Yes No Don’t Know Not Applicable

1. {If 2 = yes} What does initial patient screening for alcohol use consist of in your practice?

Informal questions (e.g. Do you drink?; How much?)

Formal screening questions/instruments (e.g. AUDIT, CAGE, CRAFFT)

Don’t know

2. {If 2 = yes} Who generally conducts the screen for alcohol use?

Nurse (including nurse practitioner)

Social worker

Behavioral health specialist

Psychologist

Physician

Medical assistant

Other (Please specify: ________________________)

3. {If 2 = yes} In your practice, is screening for alcohol use followed by some type of intervention?

No, there is no education or intervention done with the initial screening.

Yes, all patients are given educational materials/information on “safe” levels of alcohol and health risks associated with consuming too much alcohol.

Yes, patients who screen positive for risky alcohol use are asked follow-up questions and provided brief counseling.

Yes, patients 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).

4. {If 2c = yes} Who generally conducts the intervention?

Physician

Physician’s assistant

Psychologist

Social worker

Behavioral health specialist

Nurse (including nurse practitioner)

Other (Please specify: ____________________________)

4. On a scale from 1 to 5 where 1 means you completely disagree with the statement and 5 means you completely agree, to what extent do you disagree or agree with the following statements. (Select one number per row).

	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

5. On a scale from 1 to 5 where 1 means you are not confident in your skills and 5 means you are totally confident in your skills, how confident are you in your skills to do the following? (Select one number per row).

	Not at all confident in my skills	Slightly confident in my skills	Moderately confident in my skills	Very confident in my skills	Totally confident in my skills
Asking women, including pregnant women, about their alcohol use	1	2	3	4	5
Having a conversation with patients/clients who indicate risky alcohol use	1	2	3	4	5
Educating women of childbearing age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
Conducting brief interventions for reducing alcohol use	1	2	3	4	5
Utilizing resources to refer patients/clients who need formal treatment for alcohol abuse	1	2	3	4	5
Inquiring about potential prenatal alcohol exposure for my patients/clients	1	2	3	4	5
Identifying persons who may have one of the FASDs	1	2	3	4	5
Diagnosing persons who may have one of the FASDs	1	2	3	4	5
Referring patients/clients for diagnosis and/or treatment services for an FASD or alcohol use disorder	1	2	3	4	5
Managing/coordinating the treatment and care of persons who have one of the FASDs	1	2	3	4	5

6. Which of the following best describes you?

Nurse

Nurse Midwife

Midwife

Student

Other (Please specify: ________________________)

CDC estimates the average public reporting burden for this collection of information as 10 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 (0920-1129).