Medical Assistants Post-test Survey

Medical Assistants Post-test Survey

Form Approved
OMB No. XXXX-XXXX
Exp. Date xx/xx/xxxx

The course you are taking will contain presentation materials developed by the Mountain Plains Practice and Implementation Center
(PIC), located at the University of Nevada, Reno. These materials are based on content developed by the Centers for Disease Control
and Prevention (CDC).
This survey does not ask you for any personal identifying information and the results will only be used to assist us in determining the
effectiveness of the course. The course instructor will not be able to view your individual responses or know if you completed this
survey. Likewise, you are not required to complete this survey and your participation in this class will not be affected regardless of your
decision.
Thank you for your time and enjoy the class.

1. Please enter the personal ID code you created for the pretest survey.
First letter of your mother's first name

First digit of your social security number

Last digit of your social security number

First letter of your mother's maiden name

______________________________________________________________________________
The public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (XXXX-XXXX)

Medical Assistants Post-test Survey

The following items will be used only to describe the demographic makeup of the class.

2. Are you (choose one)
Male
Female

3. Are you Hispanic or Latino/a?
No
Yes

4. How do you describe your race? (check all that apply)
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White

5. In which state do you work?

6. In what type of medical setting do you work?
OB/GYN
Family medicine
Other (please specify)

Medical Assistants Post-test Survey

Please read the following statement:
Tiffany drinks more than she used to, even though she has tried to cut down or stop drinking
completely several times.
7. Please respond to the following by circling the number that most closely corresponds to your views
about Tiffany’s drinking.
Strongly disagree
I would be angry with
Tiffany for continuing to
drink.
It is Tiffany’s fault that
she drinks so much.
I would be embarrassed
for people to know that
someone in my family
has a drinking problem.
I would try to avoid
spending time with
Tiffany.
Tiffany could control her
drinking if she really
wanted to.

Disagree

Neither agree nor
disagree

Agree

Strongly agree

Medical Assistants Post-test Survey

Please read the following statement:
Although Sarah knows she is not supposed to drink alcohol while she’s pregnant, she has not
been able to stop.
8. Please respond to the following by circling the number that most closely corresponds to your views
about Sarah's drinking.
Strongly disagree
I would be angry with
Sarah for continuing to
drink.
It is Sarah's fault that
she drinks so much.
I would be embarrassed
for people to know that
someone in my family
has a drinking problem.
I would try to avoid
spending time with
Sarah.
Sarah could control her
drinking if she really
wanted to.

Disagree

Neither agree nor
disagree

Agree

Strongly agree

Medical Assistants Post-test Survey

The following items deal with factors related to fetal alcohol spectrum disorders.
9. Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term describing the range of effects that can
occur in an individual whose mother drank alcohol during pregnancy.
True
False

10. FASD is preventable if a woman does not drink during her pregnancy.
True
False

11. The effects for FASD are always visible.
True
False

12. When is it safe to drink alcohol during pregnancy?
During the first three months
During the last three months
Once in a while
Never

Medical Assistants Post-test Survey

13. How much alcohol is safe to drink during pregnancy?
One glass of wine
Two light beers
One shot of hard alcohol
None of the above

14. Screening for excessive alcohol use during pregnancy can be an effective strategy in reducing FASD.
True
False

15. On a scale of 0-10 with 0 meaning “Completely Disagree” and 10 meaning “Completely Agree” to what
extent do you agree with the following statements.
0
(Completely
disagree)

1

2

3

4

5

6

7

8

9

10
(Completely
agree)

Alcohol consumption
during pregnancy is
more prevalent in
women with lower
incomes.
Alcohol consumption
during pregnancy is
more prevalent in
women with lower
levels of education.
Alcohol consumption
during pregnancy is
more prevalent in
Anglo-white women.

16. Which of the following two statements best corresponds with your personal viewpoint (please check
only ONE box).
Occasional consumption of one standard drink alcoholic drink per day or less (i.e., 1.5 oz. hard liquor, 12 oz. of beer or 5 oz. of
wine) during pregnancy is not harmful to the mother or the fetus.
Pregnant women or women who are trying to become pregnant should completely abstain from consuming alcohol.

Medical Assistants Post-test Survey

17. On a scale from 0 to 4 where 0 means you completely disagree with the statement and 4 means you
completely agree, to what extent do you disagree or agree with the following statements.
Completely
disagree

Disagree

Neither agree nor
disagree

Agree

Completely agree

It is important to
routinely screen all
patients for alcohol use
It is important to screen
all pregnant women for
alcohol use
It is important to screen
all women of
childbearing age, for
alcohol use
I am comfortable asking
women of childbearing
age, including pregnant
women, about their
alcohol use
I am comfortable having
a conversation with
patients who indicate
risky alcohol use.
Screening for alcohol
use confers a negative
stigma to the woman
being screened.

18. Now that you have had this training, how often do you think you will talk to your patients or their
parents/caregivers about prevention of excessive alcohol use?
Never
Occasionally
About Half the Time
Frequently
Always

19. On a scale from 0 to 10 where 0 means “Not confident in my skills” and 10 means “Totally confident in
my skills,” how confident are you in your skills to do the following?
0
(Completely
disagree)
Inquire about potential
prenatal exposure for
pediatric patients
Screen women for risky
or hazardous drinking
Educate women of
childbearing age,
including those who are
pregnant about the
effects of alcohol on a
developing baby
Conduct brief
interventions for
reducing alcohol use
Utilize resources to
refer patients who need
formal treatment for
alcohol abuse

1

2

3

4

5

6

7

8

9

10
(Completely
agree)

Medical Assistants Post-test Survey

20. To what extent to you agree with the following statements?
Strongly disagree

Disagree

This training increased
my understanding of the
effects of prenatal
alcohol exposure on the
developing fetus.
The training concepts
were presented clearly.
The training was
presented in a culturally
competent and sensitive
manner.
The content will be
useful to me
professionally.
I would recommend this
presentation to others.
Overall, I am satisfied
with the quality of this
training.

21. What about this training could be improved?

22. Additional comments

Thanks for your participation!!!

Neither agree nor
disagree

Agree

Strongly agree