Inst 5 - 0970-0608 Module-specific items_revised_clean

OMB #: 0970-0608

Expiration Date: 04/30/2026

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: This collection of information will be used to understand the extent to which toolkit users might go on to apply newly acquired knowledge and skills to their work. Public reporting burden for this collection of information is estimated to average 2 minutes 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 subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-0608, Exp: 04/30/2026. If you have any comments on this collection of information, please contact Sharon Newburg-Rinn, Ph.D., Sharon.Newburg-Rinn@acf.hhs.gov.

Prenatal Alcohol and Other Drug Exposures: A Child Welfare Practice Toolkit

Module-Specific Transfer Potential and Perceived Competency Items

Thank you for considering participation in this survey, a component of the U.S. Department of Health and Human Services’ evaluation of the Prenatal Alcohol and Other Drug Exposures: A Child Welfare Practice Toolkit. The purpose of the following questions is to understand the extent to which users of this module of the toolkit might go on to apply their newly acquired knowledge and skills to their work. This information helps us to understand whether any changes need to be made to the content of this module in the future to improve its usefulness to child welfare professionals such as yourself.

We realize how limited your time is; the survey should take approximately 2 minutes to complete. Your participation in the survey is voluntary. You may decline to answer any question you do not wish to answer, and you may exit the survey at any time. There are no risks involved in participating in the survey. While you will not receive any direct benefits from participating in this survey, your responses will help us learn more about the usefulness of the toolkit.

Your survey responses will be stored in a password-protected electronic database. Only evaluation team members will be able to access survey data. Your name or any other personally identifying information will not appear in any report. Be assured that your individual responses will not be shared with your colleagues, supervisors, leadership, or any other staff of your agency. Your survey responses will remain private to the full extent permitted by law.

If you have questions or concerns about the survey or the evaluation, you may contact Project Director Erin Ingoldsby at Ingoldsby@jbassoc.com.

Please select your choice below. You may print a copy of this consent form for your records. Clicking on the “Agree” button indicates that:

• You have read the above information

• You voluntarily agree to participate

• You are 18 years of age or older

• Agree

• Disagree

[For use with the following toolkit modules: recognize, refer and coordinate, engage and partner]

Section A. Transfer Potential

Please indicate the extent to which you agree or disagree with the following statements.

		Strongly disagree	Disagree	Neutral or Unsure	Agree	Strongly agree
A-1	I feel motivated to use the (insert focus of module*) to improve my skills at work.
A-2	I feel motivated to use the (insert focus of module) as an ongoing resource at work.
A-3	My supervisor expects me to use (insert focus of module) in my work.
A-4	The information I received from (insert focus of module) can be used with my clients.
A-5	I am confident that I will use (insert focus of module) in my work.
A-6	I can identify specific cases/clients with whom (insert focus of module) content can be used.

[* For example, "I feel motivated to use the information and resources for identification processes to improve my skills at work."]

Section B. Perceived Competence

Please indicate the extent to which you agree or disagree with the following statements.

		Strongly disagree	Disagree	Neutral or Unsure	Agree	Strongly agree
B-1	Exposure to the (module name) module and resources increased my knowledge about prenatal alcohol.
B-2	Exposure to the (module name) module and resources increased my skills in addressing prenatal alcohol exposures.
B-3	Exposure to the (module name) module and resources increased my confidence in applying the knowledge highlighted in the module (e.g., [specify skill]: non-stigmatizing exploration of prenatal substance exposure history, making service referrals, offering families resources to address issues for children with prenatal alcohol exposures and their families)

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