Provider Engagement Activity Survey

Question Title

1. Please enter your information below.

First Name

Last Name

National Provider Identifier

City/Town

State/Province

ZIP/Postal Code

Question Title

2. Do you see Medi-Cal patients? (Required.)

Yes

Unsure

Not Applicable

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3. What is your race? (Select all that apply)

White

Black or African American

American Indian or Alaska Native

Asian Indian

Cambodian

Chinese

Filipino

Hmong

Japanese

Korean

Laotian

Vietnamese

Native Hawaiian

Guamanian or Chamorro

Samoan

Do not wish to disclose

Other (please specify)

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4. Are you Hispanic, Latino/a, or Spanish origin?

No, not of Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Salvadoran

Yes, Cuban

Yes, Guatemalan

Yes, Puerto Rican

Do not wish to disclose

Other Hispanic, Latino, or Spanish (please specify)

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5. Please identify your occupation: (Required.)

Physician

Nurse Practitioner

Registered Nurse/Advanced Practice Nurse

Certified Nurse Midwife/Licensed Nurse Midwife

Physician Assistant

Licensed Clinical Social Worker

Licensed Professional Clinical Counselor

Marriage and Family Therapist

Psychologist

Office Staff

Resident

Fellow

Medical Student

Student (Clinical)

Student (Non-Clinical)

Non-Clinician: Trade Association Staff

Non-Clinician: Government Staff

Non-Clinician: Non-profit/advocacy staff

Non-Clinician: Researcher

Other (please specify)

Question Title

6. Please identify your area of specialization (Required.)

N/A: I am not a clinician

Internal Medicine

Pediatrics

Medicine-Pediatrics

Obstetrics/Gynecology

Family Medicine

Behavioral Health (including social work)

Other (please specify)

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7. What organization hosted this activity?

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8. What date did you attend the activity?

Date

Question Title

9. Please select the extent to which you agree or disagree that the activity achieved the following: (Required.)

	Strongly Agree	Agree	Neither Disagree nor Agree	Disagree	Strongly Disagree	N/A
This activity enhanced my current knowledge base	This activity enhanced my current knowledge base Strongly Agree	This activity enhanced my current knowledge base Agree	This activity enhanced my current knowledge base Neither Disagree nor Agree	This activity enhanced my current knowledge base Disagree	This activity enhanced my current knowledge base Strongly Disagree	This activity enhanced my current knowledge base N/A
The educational material provided useful information for my work	The educational material provided useful information for my work Strongly Agree	The educational material provided useful information for my work Agree	The educational material provided useful information for my work Neither Disagree nor Agree	The educational material provided useful information for my work Disagree	The educational material provided useful information for my work Strongly Disagree	The educational material provided useful information for my work N/A
I am more informed about ACEs and toxic stress, trauma-informed care, and resiliency	I am more informed about ACEs and toxic stress, trauma-informed care, and resiliency Strongly Agree	I am more informed about ACEs and toxic stress, trauma-informed care, and resiliency Agree	I am more informed about ACEs and toxic stress, trauma-informed care, and resiliency Neither Disagree nor Agree	I am more informed about ACEs and toxic stress, trauma-informed care, and resiliency Disagree	I am more informed about ACEs and toxic stress, trauma-informed care, and resiliency Strongly Disagree	I am more informed about ACEs and toxic stress, trauma-informed care, and resiliency N/A
Group discussion made a positive impact on my educational experience	Group discussion made a positive impact on my educational experience Strongly Agree	Group discussion made a positive impact on my educational experience Agree	Group discussion made a positive impact on my educational experience Neither Disagree nor Agree	Group discussion made a positive impact on my educational experience Disagree	Group discussion made a positive impact on my educational experience Strongly Disagree	Group discussion made a positive impact on my educational experience N/A
After this activity, I have a stronger sense of the cross-sector nature of the ACEs Aware Initiative	After this activity, I have a stronger sense of the cross-sector nature of the ACEs Aware Initiative Strongly Agree	After this activity, I have a stronger sense of the cross-sector nature of the ACEs Aware Initiative Agree	After this activity, I have a stronger sense of the cross-sector nature of the ACEs Aware Initiative Neither Disagree nor Agree	After this activity, I have a stronger sense of the cross-sector nature of the ACEs Aware Initiative Disagree	After this activity, I have a stronger sense of the cross-sector nature of the ACEs Aware Initiative Strongly Disagree	After this activity, I have a stronger sense of the cross-sector nature of the ACEs Aware Initiative N/A

Question Title

10. Based upon the activity, do you intend to change your practice behavior? (Select all that apply)

N/A: I am not a clinician.

I need more information before I will change my practice.

I plan to complete a certified ACEs Aware Core Training

I plan to begin screening patients for ACEs.

I plan to use the information presented to reinforce my current practice.

Other (please specify)

Question Title

11. If you plan to change your practice behavior, what type of change(s) do you plan to implement? (Select all that apply)

Routine screening for ACEs in children

Routine screening for ACEs in adults

Apply the 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

N/A

Other (please specify)

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

Very confident

Somewhat confident

Unsure

Not confident

N/A

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13. 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

N/A

Other (please specify)

Provider Engagement Activity Survey

Purpose

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1. Please enter your information below.

Question Title

2. Do you see Medi-Cal patients? (Required.)

Question Title

3. What is your race? (Select all that apply)

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4. Are you Hispanic, Latino/a, or Spanish origin?

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5. Please identify your occupation: (Required.)

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6. Please identify your area of specialization (Required.)

Question Title

7. What organization hosted this activity?

Question Title

8. What date did you attend the activity?

Question Title

9. Please select the extent to which you agree or disagree that the activity achieved the following: (Required.)

Question Title

10. Based upon the activity, do you intend to change your practice behavior? (Select all that apply)

Question Title

11. If you plan to change your practice behavior, what type of change(s) do you plan to implement? (Select all that apply)

Question Title

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

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

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14. Please provide any additional feedback that you would like to share based on this engagement activity.

Provider Engagement Activity Survey

Purpose

Question Title

* 1. Please enter your information below.

Question Title

* 2. Do you see Medi-Cal patients? (Required.)

Question Title

* 3. What is your race? (Select all that apply)

Question Title

* 4. Are you Hispanic, Latino/a, or Spanish origin?

Question Title

* 5. Please identify your occupation: (Required.)

Question Title

* 6. Please identify your area of specialization (Required.)

Question Title

* 7. What organization hosted this activity?

Question Title

* 8. What date did you attend the activity?

Question Title

* 9. Please select the extent to which you agree or disagree that the activity achieved the following: (Required.)

Question Title

* 10. Based upon the activity, do you intend to change your practice behavior? (Select all that apply)

Question Title

* 11. If you plan to change your practice behavior, what type of change(s) do you plan to implement? (Select all that apply)

Question Title

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

Question Title

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

Question Title

* 14. Please provide any additional feedback that you would like to share based on this engagement activity.

1. Please enter your information below.

2. Do you see Medi-Cal patients? (Required.)

3. What is your race? (Select all that apply)

4. Are you Hispanic, Latino/a, or Spanish origin?

5. Please identify your occupation: (Required.)

6. Please identify your area of specialization (Required.)

7. What organization hosted this activity?

8. What date did you attend the activity?

9. Please select the extent to which you agree or disagree that the activity achieved the following: (Required.)

10. Based upon the activity, do you intend to change your practice behavior? (Select all that apply)

11. If you plan to change your practice behavior, what type of change(s) do you plan to implement? (Select all that apply)

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

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

14. Please provide any additional feedback that you would like to share based on this engagement activity.