Futures Without Violence ACEs Aware Supplemental Training Evaluation Form

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Systems Change and Partnership Recommendations

Which of the following best describes your primary practice setting? *

Solo Practice

Group Practice

Government

University/ Teaching System

Community Hospital

HMO/ Managed Care

Non-Profit/ Community

I do not actively practice

Other:

How long have you been in practice? *

More than 20 years

11-20 years

6-10 years

1-5 years

Less than 1 year

Approximately how many patients do you see each week? *

Less than 50

50-99

100-149

150-199

200+

I do not directly provide care

What percentage of your patients do you currently screen for ACEs? *

1-25%

26-50%

51-75%

76-100%

100%

I do not directly provide care

Please select the extent to which you agree/disagree that the activity supported the achievement of its learning objectives? *

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Identify strategies for implementing the CUES intervention with ACEs screenings

Identify key systems change strategies needed to strengthen the health care setting when addressing IPV and ACEs during clinical visits

Identify tools and resources needed to support systems change work in the health care setting

Understand opportunities available for partnership between local domestic violence programs and health care settings to better address violence and abuse.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Identify strategies for implementing the CUES intervention with ACEs screenings

Identify key systems change strategies needed to strengthen the health care setting when addressing IPV and ACEs during clinical visits

Identify tools and resources needed to support systems change work in the health care setting

Understand opportunities available for partnership between local domestic violence programs and health care settings to better address violence and abuse.

Please select the extent to which you agree/disagree that the activity achieved the following: *

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

The activity enhanced my current knowledge base.

The educational material provided useful information for my practice.

The content was evidence-based.

The cases were effective in presenting the material.

Based upon your participation in this activity, do you intend to change your practice behavior? (choose only one of the following options) *

I do plan to implement changes in my practice based on the information presented

My current practice has been reinforced by the information presented

I need more information before I will change my practice

If you plan to change your practice behavior, what type of changes do you plan to implement? * (check all that apply)

Routine screening for ACEs in children

Routine screening for ACEs in adults

Applying a clinical algorithm on ACEs and toxic stress to guide patient care

Change in treatment or management approach, based on ACEs score and toxic stress risk assessment

Change in current practice for referrals or linkages to treatment and support services

Change in interprofessional team communication or collaboration, within team in primary clinical setting

Change in interprofessional communication or collaboration, for referrals and off-site partners

Other:

How confident are you that you will be able to make your intended changes? *

Very confident

Somewhat confident

Unsure

Not confident

Which of the following do you anticipate will be the primary barrier to implementing these changes? *

Insurance/financial issues

Ability to refer to appropriate services and treatments

Time constraints

Insufficient interprofessional team support within primary clinical setting

System constraints

Treatment-related adverse events

Patient adherence/compliance

Other:

Required

Was the content of this activity fair, balanced, objective, and free of bias? * *

Yes

If no, please explain why the content of this activity was not fair, balanced, objective, and free of bias.

Please list any clinical issues/problems within your scope of practice you would like to see addressed in future educational activities, that were not addressed here:

Please include any other feedback you have on this educational experience:

Will you be needing a certification of completion for this course? *

Yes

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