Form 0920-1129 B8 Medical Assistants Change in Practice Survey

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

Medical Assistants

Change in Practice Survey

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 _____

Please respond to the items below based on your experience following the training on the impact of prenatal alcohol use and importance of doing alcohol screening and brief intervention

1. Describe the ways in which you interact with your patients has changed since the training.

2. Describe ways in which you have been able to influence overall change in practice related to screening for alcohol use where you work.

3. What factors were helpful to implementing alcohol screening and brief intervention?

4. What barriers to implementing alcohol screening and brief intervention did you experience?

5. Other things you would like us to know about the training.

Thanks for your time and participation!!!

CDC estimates the average public reporting burden for this collection of information as 15 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).