Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
“Friends”/Members of the Network Survey (Online)
You are invited to participate in this survey because you have been a friend of the Nursing Workgroup for the CDC FASD Project. The purpose of the survey is to gather information about the activities that you have engaged in related to enhancing nurses’ work in FASD prevention and/or alcohol screening and brief intervention. Your feedback is important as it will help us understand the reach and effectiveness of these efforts as well as inform refinement of the Nursing Workgroup’s future activities.
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.
What is your specialty?
Public health
Psychiatry
Perinatal/women’s health/midwifery
Other (please specify: _____________)
Which best describes your current employment? (Check all that apply.)
Staff nurse
Nurse supervisor
Nurse midwife
Nurse practitioner
Clinical nurse specialist
Nursing unit director
Healthcare organization administrator
Staff or administration at an organization that does not provide direct healthcare services
Nursing faculty
Nursing student
Other
(Please specify: _______________)
Have you shared information about FASD prevention and/or alcohol SBI promotion? YES NO
{If 3 = yes} With whom have you shared information? (Choose all that apply.)
Nurse colleagues/peers with whom I currently work
Nurses who I currently supervise
My nurse supervisor(s)
Nurse colleagues/peers other than those with whom I currently work
A network of nurses (e.g. electronic listserv; members of professional organizations)
Other medical and allied health professionals who are not nurses (e.g., physicians, medical assistants, physical therapists, etc)
My patients
Healthcare organization administrators
Policymakers
Other (Please specify: ________________________)
{If 3a = yes to shared with nurses} What kinds of information have you shared with nurses? (Choose all that apply.)
Training opportunities
Targeted communications (e.g. newsletters, infographics, social media)
Research findings (e.g. journal articles, white papers)
Resources for provider practice (e.g. pocket guides, competency checklists)
Resources for organizations (e.g. implementation guides, policy guidelines)
Other (Please specify: _____________________________)
Approximately how often do you share information?
Weekly
Monthly
Quarterly
Semi-annually
Annually
{If 3a = yes to shared with patients}
What kinds of information have you shared with your patients? (Choose all that apply.)
Research findings (e.g. journal articles, white papers)
Informational resources (e.g. tip sheets, educational brochures)
Online resources
In-person resources (e.g. support groups, treatment centers, etc.)
Other (Please specify: ______________________________)
Approximately how often do you share information?
Weekly
Monthly
Quarterly
Semi-annually
Annually
{If 3a = yes to shared with healthcare organization administrators}
What kinds of information have you shared with healthcare organization administrators? (Choose all that apply.)
Training opportunities
Research findings (e.g. journal articles, white papers)
Targeted communications (e.g. newsletters, infographics, social media)
Position statements (e.g. from national organizations)
Resources for organizations (e.g. implementation guides, policy guidelines)
Other (Please specify: _____________________________)
Approximately how often do you share information?
Weekly
Monthly
Quarterly
Semi-annually
Annually
{If 3a = yes to shared with policymakers}
What kinds of information have you shared with policymakers? (Choose all that apply.)
Training opportunities
Research findings (e.g. journal articles, white papers)
Targeted communications (e.g. newsletters, infographics, social media)
Position statements (e.g. from national organizations)
Resources for organizations (e.g. implementation guides, policy guidelines)
Other (Please specify: _____________________________)
Approximately how often do you share information?
Weekly
Monthly
Quarterly
Semi-annually
Annually
How often do you talk to your patients about their alcohol use?
Never
Occasionally
About half the time
Frequently
Always
My practice has a protocol in place to screen all patients for their alcohol use.
Yes No Don’t Know Not Applicable
i. {If 5 = yes} In your practice, what does initial patient screening for alcohol use consist of?
Informal questions (e.g. Do you drink?; How much?)
Formal screening questions/instruments (e.g. AUDIT, CAGE, CRAFFT)
Other (Please specify: ______________________________)
Don’t know
ii. {If 5 = 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).
Other (Please specify: ______________________________)
Have you participated in advocacy activities regarding FASD prevention and/or alcohol SBI? YES NO
{If 4 = yes} What advocacy activities have you participated in?
Promoting the practice of screening for alcohol use
Promoting the use of brief interventions for alcohol use
Promoting awareness of FASDs
Helping to develop and promote science-based messaging about FASD prevention and/or alcohol SBI
Participating community events (e.g. health fairs, FASD Awareness Day events)
Other (Please specify: _______________________)
Which dissemination or advocacy activities were most successful? Please explain why.
What dissemination or advocacy activities were least successful? Please explain why.
What specific changes would improve the success of dissemination and advocacy activities?
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-XXXX).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Bridget L Hanson |
| File Modified | 0000-00-00 |
| File Created | 2021-09-08 |