OBGYN Knowledge and Agency - word

Form Approved

OMB No. 0920XXXX

Exp. Date xx/xx/20xx

OBGYN SBI Knowledge and Agency

Instructions: For each item, please circle the response that best indicates how you feel today. Your responses will be kept secure, and will be summarized only in aggregate with those of other respondents. Individual, identifiable responses will NOT be shared.

1. I am confident in my ability to assess patients' Readiness to Change their drinking behavior.

1 2 3 4 5 6 7

Strongly Strongly

Agree Neutral Disagree

2. My interaction with a patient can make a difference regarding their use of alcohol.

1 2 3 4 5 6 7

Strongly Strongly

Agree Neutral Disagree

3. Patients’ concerns about confidentiality affect their willingness to be open and honest when asked about alcohol use before and during pregnancy.
   
   1 2 3 4 5 6 7

Strongly Strongly

Agree Neutral Disagree

4. Most pregnant patients decrease or stop alcohol use when they realize there is a risk to the pregnancy or the child.

1 2 3 4 5 6 7

Strongly Strongly
Agree Neutral Disagree

CDC estimates the average public reporting burden for this collection of information as 2 minutes per survey, 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 D74,

Atlanta, Georgia 30333; ATTN: PRA

(0920XXXX).

5. NIAAA recommended daily and weekly guidelines for low-risk drinking for WOMEN in general are:
   
   ___ drinks per day (a) ___ drinks per week (b)
   
   
   
   

6. Please give your best estimates for “standard drink” amount for each of the following types of alcohol:

___ oz. of wine (a) ___ oz. of beer (b) ___oz. of hard liquor (c)

Thank You for Completing!

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