Form 0920-1129 Core Pre-Test Survey

Form Approved

OMB No. 0920-1129

Exp. Date xx/xx/20xx

FASD Prevention, Identification, & Alcohol Screening Pre-Training Evaluation

Thank you for completing this survey. You are helping us to improve and identify the needs of healthcare providers in preventing and identifying fetal alcohol spectrum disorders. This survey is being conducted for the Centers for Disease Control and Prevention and will take approximately 3 minutes to complete. Your responses will be kept secure.

1. Fetal alcohol spectrum disorders are: (Check only one response.)

• 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.

2. During the past six months, did you recognize possible fetal alcohol spectrum disorders (FASD) in any of your patients?

• True

• False

3. The effects of FASDs are always visible. (Check only one response.)

• True

• False

• Don’t know

4. What advice would you give your patient/client about how much alcohol is safe to drink during pregnancy? (Check only one response.)

• One glass of wine

• One light beer

• One shot of hard alcohol

• There is no known safe amount of alcohol consumption during pregnancy.

5. Which of the following are the primary facial features associated with Fetal Alcohol Syndrome? (Check all that apply.)

• Short palpebral fissures

• Full lips

• Smooth philtrum

• Thin upper lip

• Flat nose

• Don’t know/unsure

6. On a scale from 1 to 5 where 1 means you strongly disagree with the statement and 5 means you strongly agree, to what extent do you disagree or agree with the following statements. (Select one number per row).

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
It is important to routinely screen all patients/clients for alcohol use	1	2	3	4	5
Screening a person for alcohol use confers a stigma to the person being screened	1	2	3	4	5
It is important to screen all pregnant women for alcohol use	1	2	3	4	5
It is important to screen all women of reproductive age for alcohol use	1	2	3	4	5
It is important to educate women of reproductive age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
It is important to inquire about and document potential prenatal exposure for all patients	1	2	3	4	5

7. On a scale from 1 to 5 where 1 means “Not at all confident in my skills” and 5 means “Totally confident in my skills,” how confident are you in your skills to do the following? (Select one number per row).

	Not at all confident in my skills	Slightly confident in my skills	Moderately confident in my skills	Very confident in my skills	Totally confident in my skills	Not Applicable
a. Asking women, including pregnant women, about their alcohol use	1	2	3	4	5
b. Having a conversation with patients/clients who indicate risky alcohol use	1	2	3	4	5
c. Educating women of childbearing age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
d. Conducting brief interventions for reducing alcohol use	1	2	3	4	5
e. Utilizing resources to refer patients/clients who need formal treatment for alcohol abuse	1	2	3	4	5
f. Inquiring about potential prenatal alcohol exposure for my patients/clients	1	2	3	4	5
i. Referring patients/clients for diagnosis and/or treatment services for alcohol use disorder	1	2	3	4	5

Thank you for completing the survey and for your valuable feedback!

 CDC estimates the average public reporting burden for this collection of information as 3 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, MSD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1129).