Form 0920-1129 B7 Medical Assistants Post-Test Survey

Form Approved
OMB No. 0920-1129
Exp. Date xx/xx/xxxx

Medical Assistants

Post-test Survey

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.

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

What sex were you assigned at birth, on your original birth certificate?

• Male

• Female

• Refused

• I don’t know

Do you currently describe yourself as male, female, or transgender?

• Male

• Female

• Transgender

• None of these

What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

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

In which state do you work? (specify) __________________________________

In what type of medical setting do you work?

• OB/GYN

• Family medicine

• Other (specify) _______________________________________________________________________________________

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.

Please respond to the following by circling the number that most closely corresponds to your views about Tiffany’s drinking.

	Strongly disagree	Disagree	Neither likely nor unlikely	Agree	Strongly agree
I would be angry with Tiffany for continuing to drink.	1	2	3	4	5
It is Tiffany’s fault that she drinks so much.	1	2	3	4	5
I would be embarrassed for people to know that someone in my family has a drinking problem.	1	2	3	4	5
I would try to avoid spending time with Tiffany.	1	2	3	4	5
Tiffany could control her drinking if she really wanted to.	1	2	3	4	5

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.

Please respond to the following by circling the number that most closely corresponds to your views about Sarah’s drinking.

	Strongly disagree	Disagree	Neither likely nor unlikely	Agree	Strongly agree
I would be angry with Sarah for continuing to drink.	1	2	3	4	5
It is Sarah’s fault that she drinks so much.	1	2	3	4	5
I would be embarrassed for people to know that someone in my family has a drinking problem.	1	2	3	4	5
I would try to avoid spending time with Sarah.	1	2	3	4	5
Sarah could control her drinking if she really wanted to.	1	2	3	4	5

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

1. 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

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

• True

• False

3. The effects for FASD are always visible.

• True

• False

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

• During the first three months

• During the last three months

• Once in a while

• Never

5. 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

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

• True

• False

7. 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

8. 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.

9. 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. (Circle one number per row).

	Completely Disagree	Disagree	Neither Agree nor Disagree	Agree	Completely Agree
It is important to routinely screen all patients for alcohol use	0	1	2	3	4
It is important to screen all pregnant women for alcohol use	0	1	2	3	4
It is important to screen all women of childbearing age, for alcohol use	0	1	2	3	4
I am comfortable asking women of childbearing age, including pregnant women, about their alcohol use	0	1	2	3	4
I am comfortable having a conversation with patients who indicate risky alcohol use.	0	1	2	3	4
Screening for alcohol use confers a negative stigma to the woman being screened.	0	1	2	3	4

10. 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

11. 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? (Circle one number per row).

	Not confident in my skills										Totally confident in my skills
Inquire about potential prenatal exposure for pediatric patients	0	1	2	3	4	5	6	7	8	9	10
Screen women for risky or hazardous drinking	0	1	2	3	4	5	6	7	8	9	10
Educate women of childbearing age, including those who are pregnant about the effects of alcohol on a developing baby	0	1	2	3	4	5	6	7	8	9	10
Conduct brief interventions for reducing alcohol use	0	1	2	3	4	5	6	7	8	9	10
Utilize resources to refer patients who need formal treatment for alcohol abuse	0	1	2	3	4	5	6	7	8	9	10

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
The training concepts were presented clearly.	1	2	3	4	5
The training was presented in a culturally competent and sensitive manner.	1	2	3	4	5
The content will be useful to me professionally.	1	2	3	4	5
I would recommend this presentation to others.	1	2	3	4	5
Overall, I am satisfied with the quality of this training.	1	2	3	4	5

18. What about this training could be improved? __________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

19. Additional comments: ____________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Thanks for your participation!!!

CDC estimates the average public reporting burden for this collection of information as 10 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).