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Provider Engagement Activity Survey
Purpose
Thank you for participating in a provider engagement activity funded by the ACEs Aware Initiative. Your feedback is important to us. Please take a few minutes to take our post-session survey.
1.
Please enter your information below.
First Name
Last Name
National Provider Identifier
City/Town
State/Province
ZIP/Postal Code
*
2.
Do you see Medi-Cal patients?
(Required.)
Yes
No
Unsure
Not Applicable
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)
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)
*
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)
*
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)
7.
What organization hosted this activity?
8.
What date did you attend the activity?
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*
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
Strongly Agree
Agree
Neither Disagree nor Agree
Disagree
Strongly Disagree
N/A
The educational material provided useful information for my work
Strongly Agree
Agree
Neither Disagree nor Agree
Disagree
Strongly Disagree
N/A
I am more informed about ACEs and toxic stress, trauma-informed care, and resiliency
Strongly Agree
Agree
Neither Disagree nor Agree
Disagree
Strongly Disagree
N/A
Group discussion made a positive impact on my educational experience
Strongly Agree
Agree
Neither Disagree nor Agree
Disagree
Strongly Disagree
N/A
After this activity, I have a stronger sense of the cross-sector nature of the ACEs Aware Initiative
Strongly Agree
Agree
Neither Disagree nor Agree
Disagree
Strongly Disagree
N/A
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)
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)
12.
How confident are you that you will be able to make your intended changes?
Very confident
Somewhat confident
Unsure
Not confident
N/A
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)
14.
Please provide any additional feedback that you would like to share based on this engagement activity.
