Form Dissemination Upda Dissemination Upda Dissemination Update Form

Attachment 2

State/Territory Videos Project - Dissemination Update Form

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OMB No. 0930-XXXX

Approval Expires MM/DD/YY

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-XXXX. Public reporting burden for this collection of information is estimated to average 10 minutes per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 8-1099, Rockville, Maryland, 20857.

State/Territory Videos Project - Dissemination Update Form

As you may recall, you completed a feedback form that captured information about the dissemination of your State’s/Territory’s underage drinking prevention video that was supported by the Substance Abuse and Mental Health Administration Center for Substance Abuse Prevention (SAMHSA/CSAP). At that time, you agreed to be contacted again to update the dissemination efforts of the video.

By continuing, you agree to complete this brief (approximately 10 minutes in length) online form to update the details of the dissemination of your State’s/Territory’s video. If you have any questions or concerns about completing this form, please email XXX or call (XXX) XXX-XXXX. Thank you!

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NOTE: As you complete each page of the form and click NEXT, data entered will be automatically saved. This feature allows you to return to the form to make changes or finish completing it. You will be allowed to return to the form until you click DONE.

[Programmer → Auto capture feedback form completion date. Start form on the next page.]

1. Please indicate the total dissemination efforts of your State’s/Territory’s video in each applicable category for the past 6 months:

• Website (agency) - # of views (or downloads) _____________

• Website (partner) - # of views (or downloads) _____________

• YouTube - # of views _____________

• Other social media (Please specify) _____________ - # of views (or downloads) ____________

• Distributed to partner community organizations/coalitions - # copies distributed _____________

• Mailed DVDs (excluding those mentioned above) - # copies distributed _____________

• TV (including cable & local public access) - # times broadcast _____________, viewership # _____________

• Town hall meeting/public forum presentations - # of viewers/session attendees _____________

• Conference presentations - # of viewers/session attendees _____________

• Other (Please specify) _____________ - # _____________

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<Header: State/Territory Video Project – Dissemination Update Form>

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2. Have you encountered any challenges and/or limitations in disseminating the video?

Yes	No [Programmer → Auto skip to q5]

3. What challenges and/or limitations have you encountered?

4. How were the challenges and/or limitations resolved?

5. In the past 6 months, have you received any feedback on the reaction of audiences who have been exposed to the video?

Yes	No [Programmer → Auto skip to q7]

6. What is the nature of the feedback and who provided the feedback?

7. In the past 6 months, have there been any unintended outcomes from disseminating the video?

Yes	No [Programmer → Auto skip to q9]

8. Please describe the unintended outcomes.

9. In the past 6 months, did your State/Territory receive technical assistance (TA) from the video production team?

Yes	No [Programmer → Auto skip to q14]

10. What was the nature of the TA that was received?

11. Overall, how satisfied are you with the TA your State/Territory received [from the video production team]?

Very satisfied

Somewhat satisfied

Somewhat dissatisfied

Very dissatisfied

12. To what extent has the TA you have received [from the video production team] improved your State’s/Territory’s capacity to provide effective (underage drinking) prevention services?

A great deal

Somewhat

Not very much

Not at all

Not applicable

13. To what extent have the TA recommendations your State/Territory received most recently [from the video production team] been fully implemented?

Fully

Partially

Not yet begun

14. Is there anything else that you would like to report about the dissemination of your State’s/Territory’s video or the technical assistance that you received (if any)?

Done

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[Programmer → code Exit screen after DONE to say: Thank you! You will be contacted in about 6 months to update the dissemination efforts of your State’s/Territory’s video.]