Form Community_Readines Community_Readiness_Instruments

Attachment 13 – Key Informant, Community Readiness Instruments
Document C.1: Community Readiness Assessment

OMB No. XXXX-XXXX
Expiration Date: Month Year

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 xxxx-xxxx. Public reporting burden for this
collection of information is estimated to average 20 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 7-1044, Rockville, Maryland, 20857.

Evaluation of the Native Aspirations Project
Document C.1: Community Readiness Assessment
Introductory Script
Hello, my name is ____________, and I am a community coordinator of the Native Aspirations Project.
We are conducting telephone interviews in your tribe/community to ask questions about American
Indian/Alaska Native youth violence. This project is federally funded by the Substance Abuse and Mental
Health Services Administration. I’m contacting key people and organizations in (NAME OF COMMUNITY)
that are from the areas of law enforcement, juvenile programs, school personnel, and community
members at large. The purpose of these interviews is to learn how tribes/communities are dealing with
this issue. Each interview should last about an hour and is voluntary. The entire process, including
individual names and the name of your community will be kept confidential. Our definition of youth
violence includes bullying, violence, and youth suicide.

1. Using a scale from 1 to 10, how much of a concern is AMERICAN INDIAN/ALASKA NATIVE youth
violence to the tribe/community, with 1 being not at all and 10 being a very large concern? Please
explain your rating.
2. Please describe the efforts that are available in your community to address AMERICAN
INDIAN/ALASKA NATIVE youth violence.
3. How long have these efforts been available?
4. What are the strengths of these efforts?

Community Readiness Assessment

Page 1

5. What are the weaknesses of these efforts?
6. What would you like to see added to the efforts for youth?
7. Using a scale from 1 to 10, how aware are people in the community of these efforts, with 1 being no
awareness and 10 being very aware?
8. Please explain what community members know about the efforts, such as purpose, what services
are offered, who the services are provided to, how to access the services, how effect the efforts are,
and knowledge of program data.
9. Using a scale from 1 to 10, how much of a concern is AMERICAN INDIAN/ALASKA NATIVE youth
violence to the leadership in your community, with 1 being not at all and 10 being a very large
concern? Please explain.
10. How are the leaders in your community involved in efforts regarding youth violence? Please explain.
11. Would the leadership support additional efforts? Please explain.
12. What is the community’s attitude about AMERICAN INDIAN/ALASKA NATIVE youth violence?
13. What are the primary obstacles to efforts in your community?
14. In your community, what type of information is available regarding AMERICAN INDIAN/ALASKA
NATIVE youth violence?
15. How knowledgeable are community members about AMERICAN INDIAN/ALASKA NATIVE youth
violence? Please explain. (Prompt: Do they know signs and symptoms of youth violence or local
data?)
16. What local data on this issue is available in your community?
17. How do people obtain this information in your community?
18. To whom would an individual concerned about a specific youth involved in violence turn to first for
help? Why?

Community Readiness Assessment

Page 2

19. What is the community’s attitude about supporting efforts with people volunteering time, making
financial donations, and providing space?
20. Are you aware of any proposals or action plans that have been written to address AMERICAN
INDIAN/ALASKA NATIVE youth violence in your community? If yes, please explain.
21. Do you know if there is any evaluation of these efforts? If yes, using a scale of 1 to 10, how
sophisticated is the evaluation effort, with 1 being not at all and 10 being very sophisticated.
22. Do you have any additional comments?
23. What is your gender?
24. Are you Hispanic or Latino? If yes, probe for region of Latin or Hispanic ethnicity – Puerto Rican,
Cuban, Dominican, Central American, South American, or Other.
25. What is your race?
26. How old are you?

Community Readiness Assessment

Page 3