Form No number No number Coalition Member Survey

ATTACHMENT G

Form Approved

OMB No. __0920-XXX__

Exp. Date _xx/xx/20xx_

COALITION MEMBER SURVEY

Public Reporting burden of this collection of information is estimated at 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

About You

1. Name: __________

2. Are you: male female

3. Age: (give ranges used in census)

4. Are you of Hispanic or Latino origin or descent?

• Yes

• No

5. Which of the following best describes you? (Check one or more)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

6. Who is your employer? ____________________

6. What is your job title? ____________________

6. What is your role within the coalition?

• Leader

• Member

• Other (Please explain: ________________)

6. What is your background with youth violence? (Please check all that apply)

• Formal Education

• Work Experience

• Survivor/Family History

• Advocate

• Other: (Please explain:___________________)

10. Do you represent an individual or an organization in the coalition?

• Individual

• Organization (Please provide organization’s name: ________________)

11. How would you rate your computer experience?

• Novice – I am new to computers and/or I only use one for a specific purpose.

• Low – I am somewhat new to computers and/or I am relatively comfortable with one or two software applications or programs (e.g. Microsoft Word, Excel, etc.)

• Intermediate – I am comfortable with computers and/or I have learned and use between three and ten different software applications and programs.

• Expert – I know my way around computers and/or I am comfortable troubleshooting most of the problems that arise with computers and I have used many different software applications and have some programming skills.

12. Have you visited the safeyouth.org website? Y N (If no, skip to Q26)

13. Which of the following online training courses have you completed?

• Lesson 1:

• Lesson 2:

• Lesson 3:

14. If you did not complete all three training modules, why not?

• Did not have enough time

• Did not think the training would be useful

• Did not like the training I did complete

• Already familiar with the material in the training

• Training I completed did not help me with my coalition activities

• Other (Please explain:________________________)

Safeyouth.org website

Please rate the following statements about the Safeyouth.org website on a scale of 1 to 5 with 1= Strongly Disagree to 5= Strongly Agree. If a question does not pertain to you, please write NA for not applicable.

_____15. I like the look and feel of the website.

_____16. I found the information I was looking for on the website easily.

_____17. I found interesting and useful information on the website that I wasn’t even looking for.

_____18. The website has good depth of information on youth violence prevention.

_____19. I would recommend this website to others interested in youth violence prevention.

_____20. The information provided through the online training was useful for my work within the coalition.

_____21. I found the online trainings to be engaging.

_____22. Our coalition utilized the tools available on website to help organize the coalition.

_____23. Our coalition utilized the tools on the website to conduct strategic planning activities.

_____24. Our coalition utilized the tools on the website to help support actions we are taking in our community to prevent youth violence.

_____25. Organizing and planning activities that were conducted offline, were later documented on the online workspace.

Perception of the coalition

Please rate your agreement to the statements below on a scale of 1 to 7 with 1=strongly disagree and 7=strongly agree.

_____26. Leadership has a clear vision for the coalition.

_____27. The coalition has agreed on how it will govern itself, make decisions and clarify the roles of members.

_____28. The coalition has a core group that organizes its efforts.

_____29. People in the community know what the mission and objectives of the coalition are.

_____30. The leadership has relationships with diverse groups (e.g. local businesses, religious, institutions, colleges and universities) that can help the coalition.

_____31. The coalition leadership is respected in your community.

_____32. The coalition leadership is able to mobilize resources to aid the coalition.

_____33. People involved with the coalition have or can obtain information the coalition needs to succeed.

_____34. The leadership has relationships with public officials who can help the coalition.

_____35. There is a feeling of unity and cohesion in this coalition.

_____36. It is difficult to develop a sense of trust with other coalition members.

_____37. There has been in-fighting among coalition members.

_____38. It has been difficult to get the “right” people to join the coalition – that is, people with the skills, talents or political connections needed.

_____39. It has been difficult to get coalition members to make a strong enough commitment or work hard enough on the coalition.

_____40. It has been difficult to acquire needed resources (for example, money or space).

41. What were (or do you anticipate to be) the top three challenges during the first six months of the coalition’s activities? (Please check up to three boxes)

• Recruiting diverse members

• Obtaining effective leaders

• Obtaining member participation

• Maintaining momentum

• Adapting to changes in member participation

• Orienting and training members

• Resolving conflicts and problems

• Making decisions

• Planning and goal setting

• Implementing strategies

• Evaluating progress

• Fostering collaboration

• Knowing what to do next

• Conducting a community needs assessment

• Obtaining funding

• Participating in a planning process rather than being more action oriented

42. For each of the following training/technical assistance topics, please mark whether the coalition members received any training in 2009 and will require training in 2010.

Technical Assistance Needs	Received	Needed
Evidence based planning
Conducting needs assessments
Partnering with business
Community organizing
Strategic planning and goal setting
Program sustainability
Selecting evidence based programs and curricula
Maintaining or enhancing coalition stability
Group processes and team building
Other

Community Improvement

Please rate the extent to which the following areas have changed since the coalition was formed on a scale of 1 to 7 with 1=a lot worse and 7=a great deal better.

_____43. Community-wide awareness of youth prevention programs.

_____44. Community prevention planning is systematic and comprehensive.

_____45. People are equipped to work collectively on community issues.

_____46. People feel that together we can make a difference.

_____47. Well-being of people in our community.

_____48. Local policies towards adolescent behavior problems and risk factors (e.g., schools, police, courts, county agencies, etc.).

Thank you for your time. We appreciate your input!

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