D1 Medical Assistants Change in Practice Survey_Web-based version

Medical Assistants Change in Practice Survey

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

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

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).

Medical Assistants Change in Practice Survey

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

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

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

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

Thanks for your time and participation!!!