Medical Assistants Folow-up Survey - Academic - word

Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/xxxx

Medical Assistants

Follow-up Survey (Academic)

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. Your 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.

Personal ID code: First letter of your mother’s first name ____

First letter of your mother’s maiden name ____

First digit of your social security number ____

Last digit of your social security number ____

Demographics

Are you (choose one)

• Male

• Female

Are you Hispanic or Latino(a)?

• Yes

• No

How do you describe your race? (Check all that apply.)

• American Indian/Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

The scenarios below describe the alcohol use-related behaviors of two women. Please read each scenario carefully and respond to the questions that follow.

Scenario 1

Over the past few months, Sally has started to drink more than her usual amount of alcohol. In fact, she has noticed that she now needs to drink twice as much in order to get the same effect. Several times she has tried to cut down or stop drinking. However, each time she tried she became very agitated and couldn’t sleep so would start drinking and the symptoms would go away. Her family has complained that she is often hung over, moody, and has become unreliable – making plans one day and cancelling them the next. In fact, they report that she frequently calls them while intoxicated and has no memory of the calls or what she promised the next day.

Please respond to the following by circling the number that most closely corresponds to your reaction to this situation.

In your opinion, how likely is it that Sally’s situation might be caused by…	Not at all likely	Not very likely	Neither likely nor unlikely	Somewhat likely	Very likely
her own bad character.	1	2	3	4	5
a chemical imbalance in her brain.	1	2	3	4	5
the way she was raised.	1	2	3	4	5
stressful circumstances in her life.	1	2	3	4	5
a genetic or inherited problem.	1	2	3	4	5

On a scale of 1 (Not at all) - 6 (Extremely), how likely would you be to…	Not at all likely											Extremely likely
feel ashamed if people knew someone like Sally was a member of your family?	1	2		3			4			5			6
be uncomfortable having a conversation with Sally?	1	2		3			4			5			6
be angry with Sally?	1	2		3			4			5			6
believe that Sally’s drinking is controllable?	1	2		3			4			5			6
talk with Sally about her drinking?	1	2		3			4			5			6
feel sorry for Sally?	1	2		3			4			5			6
think that Sally’s drinking is her own fault?	1	2		3			4			5			6
interview Sally for a job if you were an employer?	1	2		3			4			5			6
feel irritated with Sally?	1	2		3			4			5			6
be likely to help Sally?	1	2		3			4			5			6
feel sympathy for Sally?	1	2		3			4			5			6
believe that Sally is responsible for her drinking?	1	2		3			4			5			6
rent Sally an apartment if you were a landlord?	1	2		3			4			5			6
be concerned about Sally?	1	2		3			4			5			6
try to stay away from Sally?	1	2		3			4			5			6

Scenario 2

During the past year, Jessica has started to drink more than her usual amount of alcohol. In fact, she has noticed that she now needs to drink twice as much in order to get the same effect. Three months ago, Jessica found out that she is pregnant and her doctor told her she should not drink alcohol during her pregnancy. Jessica has tried but so far has not been able to stop drinking. Some of Jessica’s friends told her that when they were pregnant the taste and/or smell of alcohol made them sick. Jessica was hoping that she would have the same reaction, but that has not been the case. Out of concern for Jessica’s health and the health of her baby, her family has tried several times to talk with her about it. However, they are telling her that she is being selfish and not behaving in the best interest of her child. This approach is only increasing how guilty and ashamed Jessica is feeling about not being able to stop. As a result, Jessica has become very secretive about her drinking, sneaking a drink whenever she has a chance.

Please respond to the following by circling the number that most closely corresponds to your reaction to this situation.

In your opinion, how likely is it that Jessica’s situation might be caused by…	Not at all likely	Not very likely	Neither likely nor unlikely	Somewhat likely	Very likely
her own bad character.	1	2	3	4	5
a chemical imbalance in her brain.	1	2	3	4	5
the way she was raised.	1	2	3	4	5
stressful circumstances in her life.	1	2	3	4	5
a genetic or inherited problem.	1	2	3	4	5

On a scale of 1 (Not at all) - 6 (Extremely), how likely would you be to…	Not at all likely											Extremely likely
feel ashamed if people knew someone like Jessica was a member of your family?	1	2		3			4			5			6
be uncomfortable having a conversation with Jessica?	1	2		3			4			5			6
be angry with Jessica?	1	2		3			4			5			6
believe that Jessica’s drinking is controllable?	1	2		3			4			5			6
talk with Jessica about her drinking?	1	2		3			4			5			6
feel sorry for Jessica?	1	2		3			4			5			6
think that Jessica’s drinking is her own fault?	1	2		3			4			5			6
interview Jessica for a job if you were an employer?	1	2		3			4			5			6
feel irritated with Jessica?	1	2		3			4			5			6
be likely to help Jessica?	1	2		3			4			5			6
feel sympathy for Jessica?	1	2		3			4			5			6
believe that Jessica is responsible for her drinking?	1	2		3			4			5			6
rent Jessica an apartment if you were a landlord?	1	2		3			4			5			6
be concerned about Jessica?	1	2		3			4			5			6
try to stay away from Jessica?	1	2		3			4			5			6

The following items deal with factors related to fetal alcohol spectrum disorders.

5. 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

6. FASD is preventable if a woman does not drink during her pregnancy.

• True

• False

7. The effects for FASD are always visible.

• True

• False

8. When is it safe to drink alcohol during pregnancy?

• During the first three months

• During the last three months

• Once in a while

• Never

9. 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

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

• True

• False

11. 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:

Alcohol consumption during pregnancy is more prevalent in:

	Completely Disagree										Completely Agree
Women with lower incomes	0	1	2	3	4	5	6	7	8	9	10
Women with lower levels of education	0	1	2	3	4	5	6	7	8	9	10
Anglo-white women	0	1	2	3	4	5	6	7	8	9	10

12. 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.

To what extent to you agree with the following statements?	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
This training increased my understanding of the effects of prenatal alcohol exposure on the developing fetus.	1	2	3	4	5
I have applied the concepts presented in this training.	1	2	3	4	5
I have recommended this presentation to others.	1	2	3	4	5
Overall, I am satisfied with the quality of this training.	1	2	3	4	5

17. Additional comments:

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Thanks for your participation!!!

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