Form 1 Survey Instrument for Service Providers

OMB Control No: 0970-XXXX

Expiration date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.

Prenatal Alcohol and Other Drug Exposures:

Provider Survey

1. Which of the following best describes your current professional background? (Select one).

• Medical provider (e.g., primary care physician, pediatrician, nurse practitioner)

• Behavioral health or mental health provider (e.g., psychiatrist, psychologist, behavioral specialist, counselor, LPC, LSCW)

• Developmental therapist of intervention services (e.g., speech pathologist, physical therapist, occupational therapist)

• Education specialist (e.g., early intervention specialist, education specialist)

• Other (please describe) ______________________________________________

2. How many years have you provided services to children and/or families involved with [LOCAL CW AGENCY]? (Select one)

• Less than 1 year

• 1 to 5 years

• 6 to 10 years

• 11-20 years

• 21+ years

3. How many years have you provided services to children and/or families involved with the child welfare system? (Select one)

• Less than 1 year

• 1 to 5 years

• 6 to 10 years

• 11-20 years

• 21+ years

4. In the previous 12 months, how many children involved with the child welfare system have you (not your practice, but you as an individual provider) provided services to? Your best guess is fine. (Select one)

• Under 10

• 11-25

• 26-50

• 51-75

• 76-100

• Over 100

5. Please select the ages of children that you typically work with that are involved with the [LOCAL CW AGENCY]. (Select all that apply)

• Prenatal

• Newborn-less than 1

• 1-5

• 6-10

• 11-15

• 16+

This next set of questions asks about the services that you provide to children involved with [LOCAL CW AGENCY] and how you communicate with those children’s caregivers and child welfare agency staff. Please remember that this survey is anonymous and your responses will not affect your employment status or partnership with [LOCAL CW AGENCY].

6. Which of the following best describes services you, as an individual, provide to children involved with [NAME OF LOCAL CHILD WELFARE AGENCY]?

	When you do serve children involved with the child welfare agency:
	…how often do you provide this service to those children?		…how long after calling to schedule an appointment are they typically able to be seen?
	(Select the best response for each question for each row)
Medical examinations, physical health checks, or other medical treatment:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Initial screening to identify potential developmental, learning, intellectual and/or cognitive issues:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Assessment and/or diagnosis of developmental, learning, intellectual, and/or cognitive issues:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Ongoing treatment for developmental, learning, intellectual, and/or cognitive issues:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Initial screening to identify potential mental health or behavioral issues:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Assessment and/or diagnosis of mental health or behavioral issues:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Ongoing treatment for mental health or behavioral issues:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Screening, assessment and/or diagnosis to identify speech, physical therapy, and/or occupational needs:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Ongoing treatment for speech, physical therapy, and/or occupational therapy:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Referral or specific assessment of diagnosis related to prenatal alcohol exposure:	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months
Referral or specific assessment of diagnosis related to prenatal substance exposure (other than alcohol).	Routinely Occasionally	Rarely Never	Don’t provide service 1 week or less 2-6 weeks	7 weeks to 3 months 4+ months

7. Does your organization or do you as an individual have an inter-agency agreement/memo of understanding (MOU) with [LOCAL CHILD WELFARE AGENCY] to provide services to children involved with the child welfare agency?

• Yes

• No

• Don’t know

8. Among the services listed in Question 6 that you provide to children involved with [LOCAL CHILD WELFARE AGENCIES], do you tend to provide these services based on certain child characteristics (e.g. age of child, type of child welfare placement)?

• Yes, please describe any child characteristics that tend to influence your services. ________________________________________________________________________________________________________________________________________________________________________

• No, I tend to provide these services to all groups of children regardless of their age, child welfare placement type, or other characteristics and needs.

9. After providing services to a child involved with [LOCAL CHILD WELFARE AGENCY], what is the typical process you use for communicating medical needs, updated diagnoses, and/or general impressions or recommendations with case workers and/or caregivers? (Select all that apply)

• Give information at the time of appointment to child welfare agency staff/ caseworker who brings the child

• Give information at the time of appointment to family/guardian/caregiver who brings the child

• Follow-up communication to child welfare agency staff/caseworker to give results of child’s appointment

• Follow-up communication to family/guardian/caregiver to give results of child’s appointment

• Other (please describe)______________________________________

This next set of questions asks specifically about children involved with [LOCAL CHILD WELFARE AGENCY] who are known as (or suspected of) being prenatally exposed to alcohol.

10. Does the way you provide services change if you have reason to believe, or actually know, that a child has been prenatally exposed to alcohol?

• Yes, please describe how this knowledge might affect your services to the child: ________________________________________________________________________________________________________________________________________________________________________

• No.

11. Among the children involved with the [LOCAL CHILD WELFARE AGENCY], that you have personally provided services to in the previous 12 months, what percentage of children would you estimate had been prenatally exposed to alcohol? ______%

12. For children involved with [LOCAL CHILD WELFARE AGENCY], whom you suspect are prenatally exposed to alcohol, what are your three most common recommendations (this could include referrals to other services)?

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

3. ____________________________________________________________________________________

13. Does the way you provide services change if you have reason to believe, or actually know, that a child has been prenatally exposed to drugs other than alcohol?

• Yes, please describe how this knowledge might affect your services to the child: ________________________________________________________________________________________________________________________________________________________________________

• No.

14. Please consider the children involved with the [LOCAL CHILD WELFARE AGENCY] that you have personally provided services to over the previous 12 months. What percentage of those children would you estimate had been prenatally exposed to drugs other than alcohol? ______%

15. Thinking about the children involved with [LOCAL CHILD WELFARE AGENCY] who you have reason to believe may have been prenatally exposed to drugs other than alcohol, what are your three most common recommendations (this could include referrals to other services)?

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

3. ____________________________________________________________________________________

The next set of questions asks about training that you may have received about prenatal substance exposure and your level of knowledge about prenatal substance exposure. As a reminder, this survey is anonymous and your responses will not affect your employment status or partnership with [LOCAL CHILD WELFARE AGENCY].

16. Have you ever participated in courses or training about identifying or treating the physical, developmental or behavioral effects of children with prenatal substance exposure?

• Yes [go to Q17]

• No [skip to Q18]

17. Please select the types of substances that were included in those courses or trainings. Some substances listed below can fall into more than one category. (select all that apply).

• Alcohol

• Tobacco

• Marijuana

• Opioids (e.g., heroin, morphine, codeine, OxyContin, Percocet)

• Stimulants (e.g., cocaine, methamphetamine, ecstasy)

• Other illicit drugs (e.g., PCP, bath salts)

• Other misused prescription medication (e.g., Ritalin, Adderall, Xanax, etc.).

18. How would you rate your level of understanding about the development of children with prenatal exposure to alcohol? (Select one).

• No knowledge

• Beginner

• Intermediate

• Advanced

19. How would you rate your level of understanding about the development of children with prenatal exposure to drugs other than alcohol? (Select one).

• No knowledge

• Beginner

• Intermediate

• Advanced

20. In your opinion, what type of prenatal substance exposure do you think is most harmful? (select one).

• Alcohol

• Tobacco

• Marijuana

• Opioids (e.g., heroin, morphine, codeine, OxyContin, Percocet)

• Stimulants (e.g., cocaine, methamphetamine, ecstasy)

• Other illicit drugs (e.g., PCP, bath salts)

• Other misused prescription medication (e.g., Ritalin, Adderall, Xanax, etc.).

Please select either “True” or “False” to reflect your opinions and knowledge about prenatal exposure to alcohol.

21. Alcohol use during pregnancy is one of the leading known cause of developmental disability and birth defects in the United States. True False

22. Alcohol can harm an embryo or fetus at any time during pregnancy. True False

23. Women who drink early in pregnancy but stop drinking are not at risk for having a child with a Fetal Alcohol Spectrum Disorder. True False

24. Of all substances of abuse, alcohol produces the most serious neurobehavioral effects in the fetus. True False

25. There is no cure for Fetal Alcohol Spectrum Disorders, although treatment can mitigate some effects. True False

26. A woman can have 1 or 2 drinks a day without causing harm to her baby since she isn’t binging. True False

27. Fetal Alcohol Spectrum Disorders only occur if the mother is an alcoholic during pregnancy. True False

28. Most children with a Fetal Alcohol Spectrum Disorder have unusual facial features. True False

29. Please select all of the possible effects of prenatal exposure to alcohol on children. (Select all that apply).

• Growth deficits

• Brain damage

• Intellectual disability

• Abnormal facial characteristics

• Heart, lung, and kidney defects

• Hyperactivity and behavior problems

• Attention and memory problems

• Difficult with judgment, reasoning and self-regulation

• Learning disabilities

• Social issues

• Sleep problems

• Poor adaptive skills

• Neonatal Abstinence Syndrome (NAS)

• Other effects (please describe):

_________________________

Finally, these last questions ask about your general impressions and feedback about service availability as well as working with [LOCAL CHILD WELFARE AGENCY]. Please remember that the answers that you provide are anonymous and your responses will not affect your partnership with [LOCAL CHILD WELFARE AGENCY] or any staff at that agency.

30. In your local community, are there challenges in accessing services for children, or in the types of services available for children who may be affected by prenatal exposure to alcohol or other drugs? If so, please describe: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

31. From your perspective, what processes best support the identification, assessment, and treatment of children involved with [LOCAL CHILD WELFARE AGENCY] who have been prenatally exposed to alcohol or other drugs?

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your participation!

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