Download Fetal Alcohol Syndrome Questionnaire

Fetal Alcohol Syndrome Questionnaire
School Staff Survey (Pre-Workshop Assessment)
This is a survey about fetal alcohol syndrome. Your answers will help improve training programs for other school staff and
parents. Do NOT write your name on this survey. All your answers will be kept private and will never be seen by anyone
who knows you. If there is any question that you do not want to answer, just leave it blank. Please write your answers
directly on the survey. You can use either a pen or pencil.
You may have heard of various terms used to describe the conditions that can result from prenatal exposure to alcohol. These
terms include: Fetal Alcohol Syndrome (FAS), Fetal Alcohol Effects (FAE), Alcohol-Related Neurodevelopmental Disorder
(ARND), and Alcohol-Related Birth Defects (ARBD). For the purpose of this survey, FAS and ARND will be used together
(FAS/ARND) to mean FAS or ARND or other prenatal alcohol-related disorders. In some questions, FAS or ARND will be
used alone. Thank you for your participation in this survey. If you have any questions, feel free to ask the facilitator.
We will ask you to fill out another survey like this at the end of the workshop. Please fill out the matching code below so we
can compare surveys. Remember, your answers are private – you CANNOT be identified by your code. Thank you!
Month in which you were born ..................................................... ______________________
First letter of your mother’s first name .......................................... ______________________
Last letter of your last name .......................................................... ______________________
First letter of the street you live on ................................................ ______________________
1. How would you rate your current knowledge
level of Fetal Alcohol Syndrome (FAS)?
(check one)
1 None
2 A Little
3 Moderate Amount
4 A Great Deal
3. FAS/ARND is…? (check one)
1 Present only at birth
2 Usually outgrown by age two
3 Usually outgrown by puberty
4 Cured with the right treatment
5 Lifelong
2. How would you rate your current knowledge
level of Alcohol Related Neurodevelopmental
Disorder (ARND)? (check one)
1 None
2 A Little
3 Moderate Amount
4 A Great Deal
4. Please state your opinion on these issues regarding FAS/ARND ranging from Strongly Disagree to
Strongly Agree. (check one on each line)
Strongly
Disagree
Children with FAS/ARND are often misdiagnosed as only having other
conditions (i.e., Attention-Deficit/Hyperactivity Disorder).
I can tell if a child has FAS/ARND by looking at him/her.
Somewhat Somewhat
Disagree
Agree
Strongly
Agree
1
2
3
4
1
2
3
4
5. Please state your opinion on the following issues. (check one on each line)
Strongly
Disagree
I know where to go if I want more information on FAS/ARND.
I know some classroom strategies that would be helpful for children with
FAS/ARND.
I would feel able to discuss FAS/ARND with a parent.
I would feel able to discuss FAS/ARND with a colleague.
With early and ongoing support and services, children with FAS/ARND are
less likely to develop secondary conditions.
Please Continue on the Back 
Somewhat Somewhat
Disagree
Agree
Strongly
Agree
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
6. Please indicate whether each of the following statements is true or false. (check one box in each line)
Definitely
False
Alcohol has a much greater potential than cocaine to
disrupt brain growth in the fetus.
While research has helped us understand alcohol’s
effects, parents have developed many of the
interventions that help children with FAS/ARND.
Facial abnormalities are an essential feature in the
diagnosis of FAS.
Alcohol abuse during pregnancy does not always result
in the birth of a child with FAS.
The most serious effect of prenatal alcohol exposure is
growth retardation.
All children with FAS are mentally retarded.
Early diagnosis and intervention can improve the
outlook of a child with FAS.
Diagnosis of FAS/ARND is made on the basis of a
specific set of laboratory tests administered by a doctor.
Many of the simple classroom adaptations that can help
children with FAS/ARND help all children in the
classroom.
Many techniques used for children with learning
disabilities work for children affected by FAS/ARND.
Children with FAS/ARND often have problems with
sustained attention and focus.
There is a specific set of classroom strategies that work
for every child affected by FAS/ARND.
7. What is your current occupation? (check one)
1 Classroom teacher
2 Special Education teacher
3 Paraprofessional/Teacher’s aide
4 School Administrator
5 Other – Please Specify:____________
8. How long have you been in your current
position? (check one)
1 1-2 years
2 3-5 years
3 6-10 years
4 11-20 years
5 Over 20 years
9. What is your gender? (check one)
1 Male
2 Female
Probably
False
Probably
True
Definitely
True
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4
10. What is your age? (check one)
1 Under 20 years old
2 20 to 29 years old
3 30 to 39 years old
4 40 to 49 years old
5 Over 50 years old
11. What is your racial background? (check one)
1 Native American or Alaska Native:
Please Specify Tribe______________
2 Black or African American
3 Asian American
4 Native Hawaiian or Other Pacific
Islander
5 White
12. Are you Hispanic or Latino(a)? (check one)
1 Yes
2 No
Thank you for your participation!
Fetal Alcohol Syndrome Questionnaire
Parent Survey (Pre-Workshop Assessment)
This is a survey about fetal alcohol syndrome. Your answers will help improve training programs for other parents and school staff. Do
NOT write your name on this survey. All your answers will be kept private and will never be seen by anyone who knows you. If there is
any question that you do not want to answer, just leave it blank. Please write your answers directly on the survey. You can use either a pen
or pencil.
You may have heard of various terms used to describe the conditions that can result from prenatal exposure to alcohol. These terms
include: Fetal Alcohol Syndrome (FAS), Fetal Alcohol Effects (FAE), Alcohol-Related Neurodevelopmental Disorder (ARND), and
Alcohol-Related Birth Defects (ARBD). For the purpose of this survey, FAS and ARND will be used together (FAS/ARND) to mean FAS
or ARND or other prenatal alcohol-related disorders. In some questions, FAS or ARND will be used alone. Thank you for your
participation in this survey. If you have any questions, feel free to ask the facilitator.
We will ask you to fill out another survey like this at the end of the workshop. Please fill out the matching code below so we can compare
surveys. Remember, your answers are private – you CANNOT be identified by your code. Thank you!
Month in which you were born ..................................................... ______________________
First letter of your mother’s first name .......................................... ______________________
Last letter of your last name .......................................................... ______________________
First letter of the street you live on ................................................ ______________________
1.
How would you rate your current knowledge level
of Fetal Alcohol Syndrome (FAS)? (check one)
1 None
2 A Little
3 Moderate Amount
4 A Great Deal
2.
How would you rate your current knowledge level
of Alcohol Related Neurodevelopmental Disorder
(ARND)? (check one)
1 None
2 A Little
3 Moderate Amount
4 A Great Deal
4.
3.
FAS/ARND is…? (check one)
1 Present only at birth
2 Usually outgrown by age two
3 Usually outgrown by puberty
4 Cured with the right treatment
5 Lifelong
Please state your opinion on these issues regarding FAS/ARND ranging from Strongly Disagree to Strongly Agree.
(check one on each line)
Strongly Somewhat Somewhat Strongly
Disagree Disagree
Agree
Agree
Children with FAS/ARND are often misdiagnosed as only having other
conditions (i.e., Attention-Deficit/Hyperactivity Disorder).
1
2
3
I can tell if a child has FAS/ARND by looking at him/her.
1
2
3
It is important to diagnose people with FAS/ARND.
1
2
3
Different types of alcohol (wine, beer, liquor) have different risks for the baby.
1
2
3
4
4
4
4
5. Please state your opinion on the following issues. (check one on each line)
Strongly
Disagree
Somewhat Somewhat
Disagree
Agree
Strongly
Agree
I know where to go to get a child evaluated for FAS/ARND.
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
I know where to go if I want more information about FAS/ARND.
I know some parenting strategies that would be helpful for children with
FAS/ARND.
I would feel able to discuss FAS/ARND with my child’s teacher or other
school personnel.
With early and ongoing support and services, children with FAS/ARND are
less likely to develop secondary conditions.
Please Continue on the Back 
6. Please indicate whether each of the following statements is true or false. (check one box in each line)
Definitely
False
Alcohol has a much greater potential than cocaine to disrupt brain growth in the fetus.
While research has helped us understand alcohol’s effects, parents have developed many of
the interventions that help children with FAS/ARND.
Facial abnormalities are an essential feature in the diagnosis of FAS.
Alcohol abuse during pregnancy does not always result in the birth of a child with FAS.
The most serious effect of prenatal alcohol exposure is growth retardation.
All children with FAS are mentally retarded.
Early diagnosis and intervention can improve the outlook of a child with FAS.
Diagnosis of FAS/ARND is made on the basis of a specific set of laboratory tests
administered by a doctor.
Many of the simple classroom adaptations that can help children with FAS/ARND help all
children in the classroom.
Many techniques used for children with learning disabilities work for children affected by
FAS/ARND.
Children with FAS/ARND often have problems with sustained attention and focus.
There is a specific set of classroom strategies that work for every child affected by
FAS/ARND.
7.
What is your gender (check one)
1 Male
2 Female
8.
What is your age? (check one)
1 Under 20 years old
2 20 to 29 years old
3 30 to 39 years old
4 40 to 49 years old
5 50 years old or older
9.
Probably
False
Probably
True
Definitely
True
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2
3
4
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2
3
4
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3
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13. What is your job status? (check one)
1 Employed for wages
2 Currently out of work
3 Homemaker
4 Retired
5 Other - Please specify:_____________
What is your racial background? (check one)
1 Native American or Alaska Native: Please
Specify Tribe______________
2 Black or African American
3 Asian American
4 Native Hawaiian or Other Pacific
Islander
5 White
10. Are you Hispanic or Latino(a)? (check one)
1 Yes
2 No
11. What is your family income level? (check one)
1 Less than $20,000 per year
2 $20,000 to $29,000 per year
3 $30,000 to $39,000 per year
4 $40,000 to $49,000 per year
5 $50,000 per year or more
12. What is your highest level of education attained?
(check one)
1 Elementary/middle school
2 Some high school
3 High school graduate
4 Some college/technical training
5 College graduate
14. What is your marital status? (check one)
1 Single, never married
2 Legally married
3 Divorced
4 Widowed
5 Living with partner, not married
15. Do you currently have a child or children at home
with FAS/ARND? (check one)
1 Yes
2 No, SKIP TO QUESTION 17
3 I suspect my child may have FAS/ARND
4 I don’t know
16. What type of parent/guardian are you to the child
with FAS/ARND? (check one)
1 Biological parent
2 Biological relative
3 Foster parent (not biologically related)
4 Adoptive parent (not biologically related)
5 Other (including a combination of
choices above) – Please specify:
_________________________
17. If you are currently a foster parent (or have ever
been a foster parent) of a child with FAS/ARND,
have you been trained in special needs services?
1 Yes
2 No
3 I don’t Know
4 Not Applicable
Thank you for your participation!
Thank you for your participation!