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* 1. Your Name

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* 2. Your Credentials

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* 3. Your Clinic’s Name & Address

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* 4. Your Direct Phone #

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* 5. I believe that ACEs and resiliency screening is important in pediatrics

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* 6. I have an in depth understanding of ACEs, resilience and trauma informed care

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* 7. I have received training and/or education on ACEs and Resiliency

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* 8. Is someone in sr. leadership at your organization aware of the importance of ACEs and resiliency?

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* 9. What screening method/tool is your practice currently utilizing to assess for ACEs and/or resilience (Examples: General ACE Survey, Resilience Survey, Who ACE Internal Questionnaire (ACE-IQ), Center for Youth Wellness Adverse Childhood Experiences Questionnaire, The Children’s Clinic ACEs and Resilience Survey (Dr. Gillespie), Who Child Assessment, Not Applicable, etc.?)

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* 10. If your practice is currently utilizing a method to assess, what ages and/or target population do you screen?

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* 11. Does your community have the appropriate resources in place to refer parents and/or patients who need services?

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* 12. ACEs and/or resiliency screening increases the burden of screening (i.e. more time, resources, etc.)

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* 13. Identify the direct support staff (include first/last name) that will be assisting you throughout this performance improvement project?

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* 14. Identify a staff member who may be the best suited to conduct a patient chart audit (this person would be identifying which patients received a screening tool and/or resources). 

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