FASD Project Health Provider Questionnaire

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The Arc is a national nonprofit organization for people with intellectual and developmental disabilities, including Fetal Alcohol Spectrum Disorder (FASD). We want to learn about how health care providers talk to their female patients/clients about alcohol use during pregnancy. As part of our FASD Prevention Project, this 15-minute questionnaire will ask you how you and your work site currently addresses alcohol use with your patients/clients. Your responses will assist us in designing first-rate educational materials for you and other health providers to use. The FASD Prevention Project is funded through a $435,053 cooperative agreement (Grant #U1HMC26371) with the US Department of Health and Human Services Health Resources Service Administration.

By completing this questionnaire, you give The Arc permission to use this information to inform the development of provider educational and outreach materials. Your answers are confidential and will never be used to identify a specific respondent. Any answers will only be analyzed and presented in aggregate form. Any contact information you provide will be used only if you choose to receive more information about The Arc and/or FASD prevention training and materials.

If you have any questions about this survey, please contact Jennifer Sladen at sladen@thearc.org. To find out more about The Arc, visit www.thearc.org.

Contact Information

About You...

3. I am a...

Check all that apply.

About Your Work...

8. What type of employment site(s) do you work in?

Check any that apply.

10. Do you work with medically underserved populations?

Underserved populations refers to a group of persons who face economic, cultural or linguistic barriers to health care.

12. Do you provide care to girls and women of child-bearing age?

13. Which statement below best characterizes the amount of women in the community you serve that routinely receive prenatal care?

14. Do you work with American Indian and/or Alaskan Native populations?

Fetal Alcohol Spectrum Disorder has been of particular concern in some American Indian and Alaskan Native communities. Check below if you serve these communities. By checking the box, we will use your data to identify trends or issues that may be specific to this population. You may also be contacted to provide more information about your experiences working with this population.