Attachment 3 - Fee Attachment 3 - Feedback Form

Attachment 3

Town Hall Meeting Feedback Form

OMB No. 0930-0288

Expiration Date: 01/31/2011

Underage Drinking Prevention: Town Hall Meeting Feedback Form
The purpose of this form is to obtain feedback on this meeting. Please do not put your name anywhere on this form. Results will be used to inform similar future events. It is important to obtain information from all participants to maintain quality of service; however, your participation is voluntary.
Description of Meeting:
Location of Meeting:	Date of Meeting:

1. Name of organization coordinating Town Hall Meeting: _____________________________________________________________________

2. Which of the following affiliations does your organization represent for the Town Hall Meeting?

N PN lead SSA lead Coordinator/Organizer

Other (please specify) _______________________________________________

3. What was the format of the Town Hall Meeting? (Check all that apply)

P anel discussion Small group discussion

O pen forum Drama presentation

K eynote speaker Breakout sessions

Other (please specify) _____________________________________

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4. Who participated in the presentation at the Town Hall Meeting? (Check all that apply)

C ommunity leaders Education professionals

M edical professionals Human service staff

P revention specialists Local elected officials

L aw enforcement Celebrities

B usiness leaders Youth

T eachers Parents

H ealth officials Athletes

C ollege students State elected officials

Other (specify) ____________________________________________

5. What were some of the major actions taken as a result of the Town Hall Meetings (THMs)? (check all that apply)

S tarted a coalition Plan to conduct more THMs

H eld follow-up meetings Host future events

H eld discussion groups Plan legislation

Other (please specify) ________________________________________

6. What type of media promoted the Town Hall Meeting? (check all that apply)

R adio Local TV National TV

N ewspaper Live broadcast Newspaper article

N ewspaper Ads Talk show host E-mail

L istServ Brochures/Flyers Posters

V ideotaped for distribution

Other (specify) ______________________________________________

7. What was the number and composition of the Town Hall Meeting audience excluding panel participants?

A dults ________ Youth ________

8. What was the overall response of the Town Hall Meeting attendees? (check one only)

V ery positive Somewhat positive Neutral Negative

9. Did you use any of the materials provided in the Town Hall Meeting Resource Kit? (check all that apply)

L ocal statistics on underage alcohol use Video/DVD

N ational statistics on underage alcohol use Media kit

L ocal community resources

Other (please specify) ______________________________________________

10. Do you think attendees increased their awareness of the negative effects of underage use of alcohol in your community?

Yes No

11. Do you think they will become more involved in working on decreasing underage alcohol use?

Yes No

12. How will they become more involved? __________________________________________________________________________________________________________________________________________

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13. O verall, how satisfied are you with the Town Hall Meeting? (check one)

V ery dissatisfied Somewhat dissatisfied

S omewhat satisfied Very satisfied

14. Is there anything else you would like to share about your Town Hall Meeting?

_________________________________________________________________

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THANK YOU VERY MUCH FOR PARTICIPATING.

Please return this form using the provided self-addressed, stamped envelope or mail to:

Rená A. Agee

Macro International Inc.

11785 Beltsville Drive, Suite 300

Calverton, MD 20705

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 0930-0288.  Public reporting burden for this collection of information is estimated to average .167 hours 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.