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Futures Without Violence ACEs Aware Supplemental Training Evaluation Form
Systems Change and Partnership Recommendations
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* Indicates required question
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?
*
0%
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.
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
No
If no, please explain why the content of this activity was not fair, balanced, objective, and free of bias.
Your answer
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:
Your answer
Please include any other feedback you have on this educational experience:
Your answer
Will you be needing a certification of completion for this course?
*
Yes
No
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