Form Attachment 2 - Par Attachment 2 - Par Attachment 2 - Participants Survey

Attachment 2

Participants Survey

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OMB No. 0930-0288

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 0930-0288. 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.

Town Hall Meetings on Underage Drinking Prevention:

Participants Survey

The Center for Substance Abuse Prevention (CSAP) is interested in obtaining information about the Town Hall Meeting (THM) event that was held in your community. Results of this survey will be used to determine the impact of and to enhance future THM events. It is important to obtain information from a large number of participants to maintain quality of service; however, your participation is voluntary. Your answers to the questions will be kept private to the extent of the law and will not be associated with your name in any reports to CSAP. There are no known risks or benefits to you for participating in this survey. If you have any questions or concerns about your participation in this survey, please e-mail [email protected] or call 240–747–4980.

By continuing, you are consenting to participate in this survey. If you are under the age of 18, by continuing you are stating that you have received your parent’s/caregiver’s permission to participate in this survey. It will take about 10 minutes to complete. Thank you for taking the time to provide details about your participation at the THM event that was held in your community!

1. Date of THM event: MM/DD/YY

2. L

   
   
   

   ocation of THM event: City State/Territory Please Select

AL

AK

AS

AZ

(Continue through WY + Territory codes)

3. About how many people do you think attended the THM event?

• Less than 50

• Between 50 and 150

• Between 150 and 300

• Over 300

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4. Did you learn anything about underage drinking and its associated problems that you didn’t know before attending the THM event?

• Yes

• No

5. Have you shared with others any material(s) or lessons learned from the THM event?

• Yes

• No

6. With whom did you share the material(s) or lessons learned? (Mark all that apply.)

• My child/children

• Spouse

• Other relatives

• Other youth

• Other parents of teens

• Friends

• Coworkers

• Youth leaders (e.g. coaches, parks and recreation personnel, scouting leaders, etc.)

• Community leaders

• Social organizations to which I belong

• My place of employment

• Teachers

• Other school/education staff

• Education institutions

• Clergy

• Law enforcement

• Legislators

• Policymakers

• Doctors

• Other health care professionals

• Media contacts

• O

  
  
  

  ther (please specify)

7. Do you think you will become more involved in working on decreasing underage drinking in your community?

• Yes

• No

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8. If yes, how will you become more involved? (Mark all that apply.)

• Join a coalition

• Participate in a SAFE HOMES Parents Network

• Participate in follow-up meetings or discussion groups on underage drinking prevention

• Participate in an underage drinking prevention action group (e.g., committee, task force, advisory board, etc.)

• Contact my local legislators or policymakers

• Tell others about the dangers of underage drinking

• O

  
  
  

  ther (please specify)

9. Please indicate the most important underage drinking issue(s) facing your community.

(Mark all that apply.)

• Underage drinking and driving

• Alcopops

• Binge or high-risk drinking

• Underage alcohol use and risky behaviors

• Alcohol poisoning

• Lax parental attitudes toward underage drinking (e.g., parents allowing alcohol and parties in their homes; parents who see underage drinking as a harmless rite of passage, etc.)

• Lax enforcement of laws and local zoning ordinances

• Easy youth access to alcohol

• Lack of youth appeal to alcohol-free activities

• Alcohol advertising to which kids are exposed (in publications; on TV, radio, the Internet; in outdoor and transit ads)

• Alcohol sponsorship of community events that appeal to youth (e.g., sports, cultural events, music events, etc.)

• O

  
  
  

  ther (please specify)

10. To what degree do you think the THM event addressed the most important underage drinking issue(s) facing your community?

• A great deal

• Somewhat

• Not very much

• Not at all

11. The THM event was appropriate in length and duration.

• Strongly agree

• Agree

• Disagree

• Strongly disagree

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12. Overall, the presenters were knowledgeable in the areas covered in the THM.

• Strongly agree

• Agree

• Disagree

• Strongly disagree

13. Overall, the THM event was well planned and executed.

• Strongly agree

• Agree

• Disagree

• Strongly disagree

14. How old are you?

• 13 years old or younger

• 14 to 18 years old

• 19 to 24 years old

• 25 to 39 years old

• 40 to 55 years old

• 56 years old or older

15. What is your gender?

• Male

• Female

• Transgender:

  • Male to female

  • Female to male

• O

  
  
  

  ther (please specify)

16. Are you of Hispanic or Latino ethnicity?

• Yes

• No

17. What is your race? (Mark all that apply.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• W

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