Social Work and Family Physician Pre-training Survey-word

SOCIAL WORK & FAMILY PHYSICIANS PRE-TRAINING SURVEY

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

CDC estimates the average public reporting burden for this collection of information as 8 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 aCollection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Instructions: Please answer the questions below. 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. My practice has a protocol to screen all patients/clients for risky alcohol use.

 Yes  No  Don’t Know  Does not apply to my practice setting

IF YES CONTINUE, ELSE GO TO Q3.

2. What ages do you screen for risky alcohol use? ____ to ____

3. In your current position, do you provide services to women of childbearing age?

 Yes  No

IF NO, GO TO Q6

4. Fetal alcohol spectrum disorders (FASDs) are:

• Disorders a pregnant woman experiences when she drinks alcohol

• Disorders that affect the ability of a pregnant woman who drinks alcohol to go full term

• Physical disorders that affect a fetus when a pregnant woman drinks alcohol

• The range of effects that can occur in an individual who was exposed prenatally to alcohol.

5. What sources of information do you typically consult for information about FASDs?

• Colleagues

• Media

• CME/CEU Seminars

• Medical Journals/electronic databasesbooks

• Other (please specify): _____________

6. How often do you talk to your patients/clients of childbearing age or their parents/caregivers about th Colleagues

• Never

• Occasionally

• About half the time

• Frequently

• Always

• Not applicable

7. If you talk to your patients/clinets, what ages do you include? _____to _____

8. When making a decision about whether to discuss patient’s alcohol use, how important is each of the following considerations?

	Not Important	Somewhat Important	Moderately Important	Very Important	Extremely Important
a. Discussing patient/client’s alcohol use could help reduce risky drinking.	1	2	3	4	5
b. I am too busy to have time to talk to patient/clients about their alcohol use.	1	2	3	4	5
c. Discussing their alcohol use could improve my patient/clients’ health.	1	2	3	4	5
d. Helping patients/clients overcome problem drinking creates a stronger doctor-patient relationhip.
e. I do not have adequate training to deal with patient/clients’ who are at-risk drinkers.	1	2	3	4	5
f. Discussing their alcohol use could improve my patients’/clients’ work productivity.
g. Discussing alcohol issues is uncomfortable for me.	1	2	3	4	5
h. Discussing their alcohol use could improve patients’/clients’ family and personal relationships.
i. I will upset my patient/clients if I talk to them about their alcohol use.	1	2	3	4	5
j. My talking with a patient/client about alcohol use is unlikely to make a difference in his/her drinking.	1	2	3	4	5

9. Rate the importance of providing counseling to your patients/clients on risky alcohol use:

	1 Not at all important	2	3	4	5	6	7	8	9	10 Extremely important
Pregnant women.
Mothers after giving birth.
Women of childbearing age.

10. Rate your confidence in providing counseling to your patients/clients on risky alcohol use:

	1 Not at all confident	2	3	4	5	6	7	8	9	10 Extremely confident
Pregnant women.
Mothers after giving birth.
Women of childbearing age.

11. Rate the importance of discussing the following topics with your patients/clients:

With all women of childbearing age:	1 Not at all important	2	3	4	5	6	7	8	9	10 Extremely important
Contraception / family planning
Risky drinking
Risks of alcohol use during pregnancy
With women likely to conceive in the near future	1 Not at all important	2	3	4	5	6	7	8	9	10 Extremely important
d. Risky drinking
e. Risks of alcohol use during pregnancy

12. Rate your confidence in discussing the following topics with your patients/clients:

With all women of childbearing age:	1 Not at all confident	2	3	4	5	6	7	8	9	10 Extremely confident
a. Contraception / family planning
b. Risky drinking
c. Risks of alcohol use during pregnancy
With women likely to conceive in the near future:	1 Not at all confident	2	3	4	5	6	7	8	9	10 Extremely confident
d. Risky drinking
e. Risks of alcohol use during pregnancy

13. Which one of these is NOT considered a standard drink?

• 12 ounces of beer

• 12 ounces of wine cooler

• 5 ounces of wine

• 3 ounces of vodka

• All of the above are standard drinks

14. Risky drinking for nonpregnant women ages 21 and older is defined as more than____standard drinks in a day or more than ____ standard drinks per week on average:

• 2, 6

• 3, 7

• 3, 8

• 4, 7

• 4, 8

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