OBGYN Standardized Patient - word

Form Approved

OMB No. 0920XXXX

Exp. Date xx/xx/20xx

CDC estimates the average public reporting burden for this collection of information as 3 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).

OBGYN BI-MI Proficiency Rating Scale – Standardized Patient Version

Instructions immediately following Avatar SBI Encounter: Please indicate to what extent the trainee engaged in the following during this simulated screening and brief intervention, and then share specific information from items 12 and 13 with the trainee as constructive feedback to enhance their learning.

			Didn’t do this	Attempted could improve		Nearing Acceptable Skill		Done Well		Done Very Well
Asked for permission to talk about my alcohol use.			☐	☐		☐		☐		☐
Assessed quantity, frequency, and consequences of my alcohol use.			☐	☐		☐		☐		☐
Explained specific NIAAA low risk drinking guidelines, and health risks to me.			☐	☐		☐		☐		☐
Advised me to quit or cut down on alcohol use.			☐	☐		☐		☐		☐
Helped me think about pros & cons of my alcohol use.			☐	☐		☐		☐		☐
Asked how ready I am to make a change.			☐	☐		☐		☐		☐
Helped me make a plan or set a goal for decreasing (or quitting) my alcohol use.			☐	☐		☐		☐		☐
Explored my own possible reasons for quitting or cutting down on my alcohol use.			☐	☐		☐		☐		☐
Worked with me as a partner (respectfully and non-judgmentally) in addressing my substance use issues.			☐	☐		☐		☐		☐
Supported my autonomy and choice regarding my alcohol use.			☐	☐		☐		☐		☐

11. This conversation increased my motivation to cut down or quit drinking, or at least to consider doing so.
    
    1 2 3 4 5

Strongly Disagree Neutral Agree Strongly
Disagree Agree

12.* What TWO things did you like about the way the provider/trainee conducted this intervention?

1.

2.

13.* Please list TWO ways that this trainee could improve his/her skills in these conversations?

1.

2.

*Please share these comments as constructive feedback to the provider/trainee immediately following the simulated SBI session.

Thank you for your thoughtful ratings and valuable feedback!

9/13/2021 15:10 a9/p9