Form 0920-1129 Health Professionals Survey

Health Professionals Survey

Form Approved

OMB No. 0920-1129

Exp. Date xx/xx/xxxx

CDC estimates the average public reporting burden for this collection of information as 9 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 (0920-1129).

You are invited to take part in a survey for health professionals. The purpose of this survey is to understand the opinions and practices of health professionals around their patients’/clients’ alcohol use and on the prevention, identification, and treatment of fetal alcohol spectrum disorders. Your feedback is important as it will help us identify the needs of health professionals to better address the services they provide to patients/clients around alcohol consumption and/or the effects of alcohol use during pregnancy.

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 Q10

4. How often do you talk to your patients/clients of childbearing age or their parents/caregivers about alcohol use?

• Never

• Occasionally

• About half the time

• Frequently

• Always

• Not applicable

5. 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 relationship.	1	2	3	4	5
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.	1	2	3	4	5
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.	1	2	3	4	5
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

6. 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.

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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.

13. Are you aware of the CDC training website on FASD and risky alcohol use https://www.cdc.gov/fasdtraining?

Yes ______ NO ________

14. Have you taken a training on the CDC website on FASD and risky alcohol use https://www.cdc.gov/fasdtraining?

Yes ______ NO ________

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