• 1

    Your Role

  • 2

    Personal Info

  • 3

    Questionnaire

  • 4

    Complete

  • 1
    2
    3

Please indicate the option below that most accurately describes your current role/status.

  • I am a part of a medical practice and I do NOT provide clinical/medical care

  • I am a part of a medical practice and I provide clinical care, but I am not a medical provider (eg. Clinical support staff, behavioral health provider, etc.)

  • I am a part of a medical practice and I provide medical care (eg. Physician, mid-level provider, other clinical staff, etc.)

  • I am a part of a medical practice, I provide medical care AND actively screen for ACEs (eg. Physician, mid-level provider, other clinical staff, etc.)

  • I do not fall in the above categories, but I am interested in the NPPC

Your personal information

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Questionnaire

1.

Which best describes your role at your medical practice?

2.

Your Medical Practice

3.

Which best describes your medical practice?

4.

How many physical clinic sites does your medical practice have?

5.

Are you an exclusively pediatric-focused practice?

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Questionnaire

6.

Approximately how many unique pediatric patients does your practice/clinic
see annually? (Please respond based on the scope of your screening efforts
(e.g., if they are localized to one clinic site or across your entire practice) to help
 us estimate potential patients impacted by screening.)

7.

What proportion of your patients are on Medicaid, CHIP, other government assistance programs, or uninsured?

8.

To what extent do you agree with the following statements about your medical practice’s capacity for ACEs screening?

Strongly Disagree Disagree Agree Strongly Agree

Organizational support: We have broad support across providers, staff, and administration to systematically collect information on ACEs

Screening protocol and workflow: We have an established screening protocol and workflow (including administration, follow up) adopted by all providers.

Staff Support: We have policies/practices related to self-care that support the staff who are involved in the screening protocol.

Follow up/interventions: We have established referral practices to connect patients to internal and external supports and resources aimed at addressing ACEs.

Feedback loop: We have a standard way of communicating follow up between medical and non-medical providers.

Provider comfort: Most providers in our practice are comfortable talking with patients about ACEs

Training: All staff in our practice have been trained in ACEs

Patient education: We educate patients/caregivers on ACEs and toxic stress
9.

Please rate your own knowledge and comfort related to:

Needs improvement Adequate Good Outstanding

The concept of adverse childhood experiences (ACEs)

The concept of toxic stress

The short and long term health implications of ACEs for children

The short and long term health implications of ACEs for adults

The appropriate follow-up for children/parents caregivers reporting ACEs
10.

What are the barriers to screening all your pediatric patients for ACEs (current or anticipated)?

*select top 3
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Questionnaire

11.

When considering the 3 barriers you selected, how concerned are you that one or more of them might significantly stall or block progress completely?

Very Concerned

Somewhat Concerned

A Little Concerned

12.

Why do you think ACEs screening is important for your medical practice?

13.

How do you see your role related to ACEs screening?

Member Agreement

This Partnership Agreement sets forth terms and conditions for you to agree to be a “Member” of the Center for Youth Wellness (CYW) National Pediatric Practice Community.

BY CLICKING ON THE “I ACCEPT” BUTTON, YOU AGREE TO THESE TERMS AND CONDITIONS.

1. Confidentiality

CYW and “Member” acknowledge that information generated and exchanged through the NPPC offerings may be subject to confidentiality provisions of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), to laws relating to information concerning students and minors, to consent and other agreements with parents and guardians, and to other statutory and contractual requirements. CYW and “Member” will comply with such requirements as they may apply, including entering into additional confidentiality undertakings as appropriate. Federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA"). This provision is not intended and shall not act to prevent Member from fulfilling any responsibility or duty to comply with applicable federal, state, and local laws and regulations relating to mandatory reporting of child abuse or neglect. It is the responsibility of Member to comply with all applicable federal, state and local laws and regulations relating to adverse childhood experiences, including, without limitation, mandatory reporting laws applicable to Member and Member’s personnel.

2. Indemnification.

As a “Member”, you agree that each “Member” shall indemnify, defend, and hold harmless other “Members” and the Indemnified “Member’s” employees, officers, directors and subcontractors from and against any judgments, penalties, expenses, damages, or other losses incurred by the Indemnified Party based on third-party claims (including claims brought by a duly authorized regulatory authority) arising from or based upon a material breach of this Agreement or intentional misconduct resulting from the performance of the Indemnifying Party’s duties under this Agreement, alleging that the content of the PHI or personal data (as provided to the other Party) violates the privacy rights of the third party to whom the PHI or personal data relates.

3. Relationship of Parties

Nothing in these terms will be construed to create a partnership, joint venture, franchise, fiduciary, employment or agency relationship between or among the Parties, “Members”, besides as a learning community.

4. Content and Data Sharing

CYW will collect, analyze, and disseminate data about NPPC offerings. Such work is intended to allow CYW to evaluate the effectiveness of the NPPC and carry out its communication objectives. “Members” will cooperate with CYW, and other “Members” in data collection.

CYW and “Members” may share proprietary know-how, methodologies, documents and other materials. “Members” grants to CYW and other “Members” a royalty-free, non-exclusive, non-transferable, non-sublicenseable, and revocable license to use such materials for the sole purpose of benefiting the NPPC learning community. Each “Member” retains all right, title, and interest in any proprietary know-how, methodologies used or shared, or internal materials shared, without limitation.

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Your personal information

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Continue

Questionnaire

1.

Which best describes your role at your medical practice?

2.

Your Medical Practice

3.

Which best describes your medical practice?

4.

How many physical clinic sites does your medical practice have?

5.

Are you an exclusively pediatric-focused practice?

Go back
Continue

Questionnaire

6.

Approximately how many unique pediatric patients does your practice/clinic
see annually? (Please respond based on the scope of your screening efforts
(e.g., if they are localized to one clinic site or across your entire practice) to help
 us estimate potential patients impacted by screening.)

7.

What proportion of your patients are on Medicaid, CHIP, other government assistance programs, or uninsured?

8.

To what extent do you agree with the following statements about your medical practice’s capacity for ACEs screening?

Strongly Disagree Disagree Agree Strongly Agree

Organizational support: We have broad support across providers, staff, and administration to systematically collect information on ACEs

Screening protocol and workflow: We have an established screening protocol and workflow (including administration, follow up) adopted by all providers.

Staff Support: We have policies/practices related to self-care that support the staff who are involved in the screening protocol.

Follow up/interventions: We have established referral practices to connect patients to internal and external supports and resources aimed at addressing ACEs.

Feedback loop: We have a standard way of communicating follow up between medical and non-medical providers.

Provider comfort: Most providers in our practice are comfortable talking with patients about ACEs

Training: All staff in our practice have been trained in ACEs

Patient education: We educate patients/caregivers on ACEs and toxic stress
9.

What are the barriers to screening all your pediatric patients for ACEs (current or anticipated)?

*select top 3
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Questionnaire

10.

When considering the 3 barriers you selected, how concerned are you that one or more of them might significantly stall or block progress completely?

Very Concerned

Somewhat Concerned

A Little Concerned

11.

What is your role related to ACEs screening?

12.

To what extent do you think adding screening and appropriate follow up can improve care and outcomes?

Strongly Agree

Agree

Disagree

Strongly Disagree

13.

How would you rate the collaboration with medical providers on the care of shared patients?

Needs Improvement

Adequate

Good

Outstanding

14.

Please rate your own knowledge and comfort related to:

Needs improvement Adequate Good Outstanding

The concept of adverse childhood experiences (ACEs)

The concept of toxic stress

The short and long term health implications of ACEs for children

The short and long term health implications of ACEs for adults

The appropriate follow-up for children/parents caregivers reporting ACEs

Member Agreement

This Partnership Agreement sets forth terms and conditions for you to agree to be a “Member” of the Center for Youth Wellness (CYW) National Pediatric Practice Community.

BY CLICKING ON THE “I ACCEPT” BUTTON, YOU AGREE TO THESE TERMS AND CONDITIONS.

1. Confidentiality

CYW and “Member” acknowledge that information generated and exchanged through the NPPC offerings may be subject to confidentiality provisions of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), to laws relating to information concerning students and minors, to consent and other agreements with parents and guardians, and to other statutory and contractual requirements. CYW and “Member” will comply with such requirements as they may apply, including entering into additional confidentiality undertakings as appropriate. Federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA"). This provision is not intended and shall not act to prevent Member from fulfilling any responsibility or duty to comply with applicable federal, state, and local laws and regulations relating to mandatory reporting of child abuse or neglect. It is the responsibility of Member to comply with all applicable federal, state and local laws and regulations relating to adverse childhood experiences, including, without limitation, mandatory reporting laws applicable to Member and Member’s personnel.

2. Indemnification.

As a “Member”, you agree that each “Member” shall indemnify, defend, and hold harmless other “Members” and the Indemnified “Member’s” employees, officers, directors and subcontractors from and against any judgments, penalties, expenses, damages, or other losses incurred by the Indemnified Party based on third-party claims (including claims brought by a duly authorized regulatory authority) arising from or based upon a material breach of this Agreement or intentional misconduct resulting from the performance of the Indemnifying Party’s duties under this Agreement, alleging that the content of the PHI or personal data (as provided to the other Party) violates the privacy rights of the third party to whom the PHI or personal data relates.

3. Relationship of Parties

Nothing in these terms will be construed to create a partnership, joint venture, franchise, fiduciary, employment or agency relationship between or among the Parties, “Members”, besides as a learning community.

4. Content and Data Sharing

CYW will collect, analyze, and disseminate data about NPPC offerings. Such work is intended to allow CYW to evaluate the effectiveness of the NPPC and carry out its communication objectives. “Members” will cooperate with CYW, and other “Members” in data collection.

CYW and “Members” may share proprietary know-how, methodologies, documents and other materials. “Members” grants to CYW and other “Members” a royalty-free, non-exclusive, non-transferable, non-sublicenseable, and revocable license to use such materials for the sole purpose of benefiting the NPPC learning community. Each “Member” retains all right, title, and interest in any proprietary know-how, methodologies used or shared, or internal materials shared, without limitation.

Go back

Your personal information

Go back
Continue

Questionnaire

1.

Which best describes your role at your medical practice?

2.

Your Medical Practice

3.

Which best describes your medical practice?

4.

How many physical clinic sites does your medical practice have?

5.

Are you an exclusively pediatric-focused practice?

Go back
Continue

Questionnaire

6.

Approximately how many unique pediatric patients does your practice/clinic
see annually? (Please respond based on the scope of your screening efforts
(e.g., if they are localized to one clinic site or across your entire practice) to help
 us estimate potential patients impacted by screening.)

7.

What proportion of your patients are on Medicaid, CHIP, other government assistance programs, or uninsured?

8.

To what extent do you agree with the following statements about your medical practice’s capacity for ACEs screening?

Strongly Disagree Disagree Agree Strongly Agree

Organizational support: We have broad support across providers, staff, and administration to systematically collect information on ACEs

Screening protocol and workflow: We have an established screening protocol and workflow (including administration, follow up) adopted by all providers.

Staff Support: We have policies/practices related to self-care that support the staff who are involved in the screening protocol.

Follow up/interventions: We have established referral practices to connect patients to internal and external supports and resources aimed at addressing ACEs.

Feedback loop: We have a standard way of communicating follow up between medical and non-medical providers.

Provider comfort: Most providers in our practice are comfortable talking with patients about ACEs

Training: All staff in our practice have been trained in ACEs

Patient education: We educate patients/caregivers on ACEs and toxic stress
9.

Please rate your own knowledge and comfort related to:

Needs improvement Adequate Good Outstanding

The concept of adverse childhood experiences (ACEs)

The concept of toxic stress

The short and long term health implications of ACEs for children

The short and long term health implications of ACEs for adults

The appropriate follow-up for children/parents caregivers reporting ACEs
Go back
Continue

Questionnaire

10.

Patients in need of additional services outside of primary care (behavioral health services, specialty services or other supportive community-based resources)

11.

Which of the following best describes your current status of systematically collecting information related to ACEs from your pediatric patients (or their parents/caregivers)?

12.

To what extent do you agree with the following statements about YOUR capacity for ACEs screening?

Strong Disagree Disagree Agree Strongly Agree

I’m comfortable talking with patients about ACEs

I have been trained in ACEs

Administering ACEs screening is part of my standard practice

I routinely educate patients/caregivers on ACEs and toxic stress
13.

What are the barriers to screening all your pediatric patients for ACEs (current or anticipated)?

*select top 3
14.

When considering the 3 barriers you selected, how concerned are you that one or more of them might significantly stall or block progress completely? (3 point linear scale: very concerned, somewhat concerned, a little concerned)

Very Concerned

Somewhat Concerned

A little concerned

Member Agreement

This Partnership Agreement sets forth terms and conditions for you to agree to be a “Member” of the Center for Youth Wellness (CYW) National Pediatric Practice Community.

BY CLICKING ON THE “I ACCEPT” BUTTON, YOU AGREE TO THESE TERMS AND CONDITIONS.

1. Confidentiality

CYW and “Member” acknowledge that information generated and exchanged through the NPPC offerings may be subject to confidentiality provisions of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), to laws relating to information concerning students and minors, to consent and other agreements with parents and guardians, and to other statutory and contractual requirements. CYW and “Member” will comply with such requirements as they may apply, including entering into additional confidentiality undertakings as appropriate. Federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA"). This provision is not intended and shall not act to prevent Member from fulfilling any responsibility or duty to comply with applicable federal, state, and local laws and regulations relating to mandatory reporting of child abuse or neglect. It is the responsibility of Member to comply with all applicable federal, state and local laws and regulations relating to adverse childhood experiences, including, without limitation, mandatory reporting laws applicable to Member and Member’s personnel.

2. Indemnification.

As a “Member”, you agree that each “Member” shall indemnify, defend, and hold harmless other “Members” and the Indemnified “Member’s” employees, officers, directors and subcontractors from and against any judgments, penalties, expenses, damages, or other losses incurred by the Indemnified Party based on third-party claims (including claims brought by a duly authorized regulatory authority) arising from or based upon a material breach of this Agreement or intentional misconduct resulting from the performance of the Indemnifying Party’s duties under this Agreement, alleging that the content of the PHI or personal data (as provided to the other Party) violates the privacy rights of the third party to whom the PHI or personal data relates.

3. Relationship of Parties

Nothing in these terms will be construed to create a partnership, joint venture, franchise, fiduciary, employment or agency relationship between or among the Parties, “Members”, besides as a learning community.

4. Content and Data Sharing

CYW will collect, analyze, and disseminate data about NPPC offerings. Such work is intended to allow CYW to evaluate the effectiveness of the NPPC and carry out its communication objectives. “Members” will cooperate with CYW, and other “Members” in data collection.

CYW and “Members” may share proprietary know-how, methodologies, documents and other materials. “Members” grants to CYW and other “Members” a royalty-free, non-exclusive, non-transferable, non-sublicenseable, and revocable license to use such materials for the sole purpose of benefiting the NPPC learning community. Each “Member” retains all right, title, and interest in any proprietary know-how, methodologies used or shared, or internal materials shared, without limitation.

Go back

Your personal information

Go back
Continue

Questionnaire

1.

Which best describes your role at your medical practice?

2.

Your Medical Practice

3.

Which best describes your medical practice?

4.

How many physical clinic sites does your medical practice have?

5.

Are you an exclusively pediatric-focused practice?

Go back
Continue

Questionnaire

6.

Approximately how many unique pediatric patients does your practice/clinic
 see annually? (Please respond based on the scope of your screening efforts
(e.g., if they are localized to one clinic site or across your entire practice) to help
 us estimate potential patients impacted by screening.)

7.

What proportion of your patients are on Medicaid, CHIP, other government assistance programs, or uninsured?

8.

To what extent do you agree with the following statements about your medical practice’s capacity for ACEs screening?

Strongly Disagree Disagree Agree Strongly Agree

Organizational support: We have broad support across providers, staff, and administration to systematically collect information on ACEs

Screening protocol and workflow: We have an established screening protocol and workflow (including administration, follow up) adopted by all providers.

Staff Support: We have policies/practices related to self-care that support the staff who are involved in the screening protocol.

Follow up/interventions: We have established referral practices to connect patients to internal and external supports and resources aimed at addressing ACEs.

Feedback loop: We have a standard way of communicating follow up between medical and non-medical providers.

Provider comfort: Most providers in our practice are comfortable talking with patients about ACEs

Training: All staff in our practice have been trained in ACEs

Patient education: We educate patients/caregivers on ACEs and toxic stress
9.

Please rate your own knowledge and comfort related to:

Needs improvement Adequate Good Outstanding

The concept of adverse childhood experiences (ACEs)

The concept of toxic stress

The short and long term health implications of ACEs for children

The short and long term health implications of ACEs for adults

The appropriate follow-up for children/parents caregivers reporting ACEs
Go back
Continue

Questionnaire

10.

Patients in need of additional services outside of primary care (behavioral health services, specialty services or other supportive community-based resources)

11.

Which answer best fits the extent you have a standard screening work flow in place?

I screen without a protocol I screen using a set protocol Some other providers in my practice screen without a protocol Some other providers in my practice screen with an agreed upon protocol All providers in my practice screen with an agreed upon protocol

Some Patients

Most Patients
12.

Who is being screened?

13.

How often are you doing the screening? (check all that apply)

14.

To what extent do you agree with the following statements about YOUR capacity for ACEs screening?

Strong Disagree Disagree Agree Strongly Agree

I’m comfortable talking with patients about ACEs

I have been trained in ACEs

Administering ACEs screening is part of my standard practice

I routinely educate patients/caregivers on ACEs and toxic stress
15.

What are the barriers to screening all your pediatric patients for ACEs (current or anticipated)?

*select top 3
16.

When considering the 3 barriers you selected, how concerned are you that one or more of them might significantly stall or block progress completely?

Very Concerned

Somewhat Concerned

A little concerned

Member Agreement

This Partnership Agreement sets forth terms and conditions for you to agree to be a “Member” of the Center for Youth Wellness (CYW) National Pediatric Practice Community.

BY CLICKING ON THE “I ACCEPT” BUTTON, YOU AGREE TO THESE TERMS AND CONDITIONS.

1. Confidentiality

CYW and “Member” acknowledge that information generated and exchanged through the NPPC offerings may be subject to confidentiality provisions of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), to laws relating to information concerning students and minors, to consent and other agreements with parents and guardians, and to other statutory and contractual requirements. CYW and “Member” will comply with such requirements as they may apply, including entering into additional confidentiality undertakings as appropriate. Federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA"). This provision is not intended and shall not act to prevent Member from fulfilling any responsibility or duty to comply with applicable federal, state, and local laws and regulations relating to mandatory reporting of child abuse or neglect. It is the responsibility of Member to comply with all applicable federal, state and local laws and regulations relating to adverse childhood experiences, including, without limitation, mandatory reporting laws applicable to Member and Member’s personnel.

2. Indemnification.

As a “Member”, you agree that each “Member” shall indemnify, defend, and hold harmless other “Members” and the Indemnified “Member’s” employees, officers, directors and subcontractors from and against any judgments, penalties, expenses, damages, or other losses incurred by the Indemnified Party based on third-party claims (including claims brought by a duly authorized regulatory authority) arising from or based upon a material breach of this Agreement or intentional misconduct resulting from the performance of the Indemnifying Party’s duties under this Agreement, alleging that the content of the PHI or personal data (as provided to the other Party) violates the privacy rights of the third party to whom the PHI or personal data relates.

3. Relationship of Parties

Nothing in these terms will be construed to create a partnership, joint venture, franchise, fiduciary, employment or agency relationship between or among the Parties, “Members”, besides as a learning community.

4. Content and Data Sharing

CYW will collect, analyze, and disseminate data about NPPC offerings. Such work is intended to allow CYW to evaluate the effectiveness of the NPPC and carry out its communication objectives. “Members” will cooperate with CYW, and other “Members” in data collection.

CYW and “Members” may share proprietary know-how, methodologies, documents and other materials. “Members” grants to CYW and other “Members” a royalty-free, non-exclusive, non-transferable, non-sublicenseable, and revocable license to use such materials for the sole purpose of benefiting the NPPC learning community. Each “Member” retains all right, title, and interest in any proprietary know-how, methodologies used or shared, or internal materials shared, without limitation.

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Your personal information

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Questionnaire

1.

How did you hear about the National Pediatric Practice Community?

2.

Why are you interested in the National Pediatric Practice Community?

3.

Is there content that you have developed that you would like to share with the National Pediatric Practice Community?

4.

Do you have access to a network of medical providers or practices that would be interested in the NPPC and/or receiving technical assistance?

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