Appendix 5 Natural Exposure Follow-up Survey

APPENDIX 5: NATURAL EXPOSURE FOLLOW-UP SURVEY

OMB No. 0930-0196

Expiration Date: 09/30/2013

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 0930-0196. Public reporting burden for this collection of information is estimated to average 10 minutes per respondent per year, as no time is necessary for reviewing instructions, searching existing data sources, gathering and maintaining data, nor 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.

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Application ID#:

URL:

DRAFT – April 20, 2012

Project Registration #	__N__ TRANSLATIONS
City Center:	X SURVEY DESIGN:
CSAP Natural Exposure Follow-up
Lloyd/Purcell	__N__ PANEL SAMPLE
Mark Rupprecht, Programmer
February, 2012	n=500

SA. NAME:(Code from oms):

(Prefix/First Name/Last Name/Suffix)

Sb. FORM: (Code from oms)

1 PILOT SITE A Attendee

2 PILOT SITE b Attendee

3 PILOT SITE c Attendee

4 PILOT SITE d Attendee

5 PILOT SITE e Attendee

SC. event type: (code from oms)

1 if SB=1 event type is <PILOT SITE A event>

2 if SB=2 event type is <PILOT SITE b event>

3 if SB=3 event type is <PILOT SITE c event>

4 if SB=4 event type is <PILOT SITE d event>

5 if SB=5 event type is <PILOT SITE e event>

SD. event DATE: (code from oms)

1 if SB=1 event DATE is <PILOT SITE A event>

2 if SB=2 event DATE is <PILOT SITE b event>

3 if SB=3 event DATE is <PILOT SITE c event>

4 if SB=4 event DATE is <PILOT SITE d event>

5 if SB=5 event DATE is <PILOT SITE e event>

Welcome to The Gallup Underage Drinking Prevention

Survey.

This survey will only take you a few minutes to complete. Please enter your ID Code from the e-mail invitation you received earlier and click the "Begin Survey" button to continue.

ID Code

<Begin Survey>

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Do not print, store, or copy this page.

Copyright © 1994-2000, 2012 Gallup, Inc. All rights reserved. Privacy Policy

Dear (Prefix/First Name/Last Name/Suffix):

We would like to thank you for agreeing to participate in this study. It is important that your opinions be heard.

This survey is a follow-up to the survey you took a

few months ago. We would like to get your feedback on

the you information you received on underage drinking

prevention at (CODE EVENT TYPE BASE ON SC).

If you do not complete the survey in one sitting, you can log on again and the survey will resume where you left off. You will not have to repeat any of the questions you have already answered.

Your responses are confidential. Gallup will never release any of your information.

Thank you in advance for your valued input.

S1. Just to confirm, are you (Prefix/First Name/Last Name/Suffix)?

1 Yes

2 No

(Error Message:)

A response is required to continue.

S2. Did you attend the <CODE EVENT TYPE BASE ON SC> on CODE EVENT DATE AND LOCATION>

1 Yes

2 No

(Error Message:)

A response is required to continue.

(If code 1 in S2, Skip to Q1; Otherwise, Continue)

We're sorry, but this survey was intended for (Prefix/First Name/Last Name/Suffix) who attended <CODE EVENT TYPE BASE ON SC> on CODE EVENT DATE AND LOCATION>.

If you feel you have received this message in error, or if you have questions about this survey, please contact Gallup Client Support at [email protected] or call 1-888-297-8999.

Thank you. You may now close your browser or go to another Web site.

For the following questions, I want you to think about your

child/children who are between the ages of 9 and 15.

Q1. Currently, do you see drinking alcohol as an issue to be concerned about regarding your child/children?

1. Yes

2. No

Q2. Do you think there is anything you could do to prevent your child/children from drinking alcohol?

1 Yes (IF CODE 1 in Q2 continue)

2 No (SKIP TO Q4)

Q2a. What could you do to prevent your child/children from drinking alcohol? (Fill in response) (Allow 400 characters)

Q3. Have you ever had a conversation with your child/children about alcohol?

1. Yes (IF CODE 1 in Q3 continue)

2. No (SKIP TO Q4)

Q3a. Within the last 3 months, how often have you talked to your child/children about drinking alcohol?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6 Not at all in the 3 months

Q3b. Within the last 3 months, how often have you talked to your child/children about dangers of drinking alcohol?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6 Not at all in the 3 months

Q4. Have you talked with the parents of your child’s/children’s friends about their children drinking alcohol?

1. Yes (IF CODE 1 in Q3 continue)

2. No (SKIP TO Q5)

Q4a. Within the last 3 months, how often have you talked with the parents of your child’s/children’s friends about children drinking alcohol?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6 Not at all in the 3 months

Q5. If you were concerned or wanted to find information about preventing your child/children from drinking alcohol, where would you go to find information to help you address this concern? (Fill in response) (Allow 400 characters)

Q6. Without looking back at any of the materials you received at (CODE EVENT TYPE BASE ON SC) about underage drinking, what organization sponsored them?

1 CDC

2 SAMHSA

3 HHS

4 NIH

8 Don't know

Q7. How likely would you be to seek out more information about this organization?

1 Not at all likely

2

3

4

5 Extremely likely

Q8. Thinking about all the materials and information you received at <CODE EVENT TYPE BASE ON SC> about underage drinking, please describe what you found most useful? Please be as specific as possible. (Fill in response) (Allow 400 characters)

Q9. How relevant would you say these materials are to you?

1. Not at all relevant

2

3

4

5 Extremely relevant

Q10. Did the materials leave an impression on you?

1. Did not leave an impression

2

3

4

5 Left impression

Q11. To what extent did you like these materials?

1 Did not like it at all

2

3

4

5 Liked it a lot

(If 1, 2, or 3 in #Q11, Continue;

If No response, go to #Q12;

Otherwise, Skip to Q11B)

Q11A. What didn’t you like about them? (Fill in response) (Allow 200 characters)

(All in #11A, Skip to #12)

Q11B. What did you like about them? (Fill in response (Allow 200 characters)

Q12. How likely are you to take any of the following actions related to your child/children and underage drinking?

A. Have a conversation with your child/children about underage drinking in the next 30 days?

5 Very likely

4

3

2

1 Not at all likely

7 DK

B. Let your child/children know how you feel about him/her drinking?

5 Very likely

4

3

2

1 Not at all likely

7 DK

C. Talk to your child’s/children’s friends’ parents about underage drinking?

5 Very likely

4

3

2

1 Not at all likely

7 DK

D. Search the Internet for more information about underage drinking?

5 Very likely

4

3

2

1 Not at all likely

7 DK

F. Learn more about where your child/children is/are?

5 Very likely

4

3

2

1 Not at all likely

7 DK

G. Learn more about who your child’s/children’s friends are?

5 Very likely

4

3

2

1 Not at all likely

7 DK

H. Learn more about who your child/children is/are with?

5 Very likely

4

3

2

1 Not at all likely

7 DK

I. Monitor your child’s/children’s online activity?

5 Very likely

4

3

2

1 Not at all likely

7 DK

Q13. Since attending the <CODE EVENT TYPE BASE ON SC>, have you visited the Web site www.underagedrinking.samhsa.gov ?

1. Yes (IF CODE 1 continue)

2. No (SKIP TO Q14)

Q13a. How many times have you visited the Web site?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6 Not at all

Q14. How likely are you to visit the www.underagedrinking.samhsa.gov Web site for more information?

5 Very likely

4

3

2

1 Not at all likely

7 DK

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<Submit Survey>

Thank you for participating in The Gallup Underage Drinking Prevention Survey.

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Gallup POLL 2012 CSAP UAD NATURAL EXPOSURE FOLLOW-UP SURVEY Web 02/02/21