Family Medicine Evaluation

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Family Medicine

Evaluation Questions Addendum for Practice or Individual Provider

Patients/clients Screened and Provided Intervention/Referral

All Questions Refer to the Past 6 Months

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. How many unique pediatric patients/clients/clients have you seen? Has the practice seen?

2. How many patients/clients/clients did you screen/were screened for FASD?

3. How many patients/clients/clients screened positive for FASD?

4. How many patients/clients/families were referred for further assessment and/or treatment of FASD?

5. How many unique patients/clients age 9 and older have you seen? Has the practice seen?

6. How many patients/clients did you screen/were screened for alcohol use using validated screening questions/tools?

7. How many patients/clients screened positive for risky alcohol use?

8. How many patients/clients screening positive for risky alcohol use received a brief intervention?

9. How many patients/clients were determined likely to have an alcohol use disorder?

10. How many patients/clients were referred for alcohol use disorder treatment?

11. How many unique, non pregnant female patients/clients age 14 to 44 years old did you see/has the practice seen? (If zero, go to question 12).

1. How many of these patients/clients received pregnancy risk assessment?

2. How many of these patients/clients were assessed as at risk for pregnancy? (post menarche, sexually active with at least one male partner , not using contraception effectively or at all, and not sterile)

3. How many of these patients/clients expressed desire for pregnancy in the next 6 months?

4. How many of these patients/clients received pregnancy prevention counseling?

5. How many of these patients/clients received effective contraception services and/or prescriptions?

6. How many of these patients/clients received alcohol screening?

7. How many of these patients/clients screening positive for risky alcohol use received a brief intervention?

8. How many of these patients/clients were determined likely to have an alcohol use disorder?

9. How many of these patients/clients were referred for alcohol use disorder treatment?

10. How many of these patients/clients were referred for a CHOICES intervention? – for practices integrating CHOICES only

12. How many unique, pregnant patients/clients did you see/has the practice seen? (If zero, go to question 13).

1. How many of these patients/clients received alcohol screening?

2. How many of these patients/clients screened positive for any alcohol use during their current pregnancy?

3. How many of these patients/clients screening positive for alcohol use received a brief intervention?

4. How many of these patients/clients were determined likely to have an alcohol use disorder?

5. How many of these patients/clients were referred for alcohol use disorder treatment?

6. How many of these patients/clients screening positive for alcohol use were asked about prior alcohol exposed pregnancies, children with FASD?

7. How many of these patients/clients screening positive for alcohol use were given information and resources on FASD and alcohol exposed pregnancies?

13. Is an FASD screening template integrated into the practice EMR? Yes / No

14. Is an SBI template integrated into the practice EMR? Yes / No

15. Is a pregnancy risk template integrated into the practice EMR? Yes / No

16. 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. (Circle one number per row).
    
    

	Completely Disagree	Disagree	Neither Agree nor Disagree	Agree	Completely Agree
I feel comfortable in my SBI role within this practice/clinic.	1	2	3	4	5
I feel confident in my SBI role within this practice/clinic.	1	2	3	4	5
I feel comfortable in my FASD screening and referral role within this practice/clinic.	1	2	3	4	5
I feel confident in my FASD screening and referral role within this practice/clinic.	1	2	3	4	5
I feel comfortable in my pregnancy risk reduction role within this practice/clinic.	1	2	3	4	5
I feel confident in my pregnancy risk reduction role within this practice/clinic.	1	2	3	4	5

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 Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX). Page 2