Attachment 1
Organizers Survey
<Opening Page>
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 .500 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: Organizers Survey
INFORMED CONSENT STATEMENT
Congratulations on your participation in the Town Hall Meetings (THMs) on Underage Drinking Prevention initiative! You may recall that as a participant in the THMs initiative, your organization agreed to complete a survey regarding the THM event that was held in your community. The survey will take about 30 minutes to complete. The information collected will be used to enhance future THM events and will help the Substance Abuse and Mental Health Services Administration (SAMHSA) determine the impact of this nationwide initiative.
It is important to obtain information from a large number of participants to maintain quality of service; however, your participation is voluntary. Taking the survey will cause little or no risk to you and/or your organization. The potential risks include the breach of confidentiality of non-sensitive information (such as organization name) and the emotional discomfort associated with completing any survey. The information you provide will be kept private to the extent of the law and will not be associated with your or your organization’s name in any reports to SAMHSA. The findings reported to SAMHSA will be in group form. If you have any questions or concerns about participating in this survey, please e-mail [email protected] or call the Town Hall Meeting information line at 240-747-4980.
By continuing, you are consenting to participate in this survey on behalf of your organization.
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NOTE: As you complete each page of the survey and click NEXT, data entered will be automatically saved. This feature allows you to return to the survey to make changes or finish completing it. You will be allowed to return to the survey until you click DONE.
<Header: Town Hall Meetings on Underage Drinking Prevention: Organizers Survey>
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Please mark here if the Town Hall Meeting (THM) event was not held |
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Please state the reason why the THM event was not held |
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If a THM event was not held in your community, please go to the last page of this survey and hit DONE.
Date of Town Hall Meeting (THM) event: MM/DD/YY
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(Continue through WY + Territory codes)
In what venue was this THM event held?
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How would you characterize the location where the THM event was held?
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How long did the THM event last? # hours # minutes
What organization(s) coordinated the THM event?
Were youth involved in organizing and/or planning the THM event?
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Was the topic of the THM event solely on underage drinking?
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If no, what other topics were discussed?
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How was the THM event promoted in the community? (Mark all that apply)
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What was the total number of THM event attendees? (Estimates are okay)
Based on the total number of THM event attendees provided in question 11, please estimate the number of THM event attendees in each age category.
# 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
Based on the total number of THM event attendees provided in question 11, please estimate the number of THM event attendees in each gender category.
#
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Based on the total number of THM event attendees provided in question 11, please estimate the number of THM event attendees in each racial/ethnic group.
# American Indian or Alaska Native
# Asian
# Black or African American
# Hispanic or Latino
# Native Hawaiian or Other Pacific Islander
# White
In what language(s) was(were) the THM event conducted? (Mark all that apply.)
English
Spanish
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Which of the following was a feature of the THM event? (Mark all that apply.)
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Did you use any material(s) from www.stopalcoholabuse.gov for the THM event?
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<Header: Town Hall Meetings on Underage Drinking Prevention: Organizers Survey>
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If yes, what material(s) did you use? (Mark all that apply.)
How To
Community Briefing Prevention Toolkit: Town Hall Meetings
First Steps: Examples to help you decide on your meeting scale
Getting Started: Suggestions for organizing your planning committee
Planning the Town Hall Meeting: Checklists for ensuring a successful event before, the day of, and after your meeting
Meeting Facilitation: Facilitator’s checklist for keeping your meeting on track
Media Outreach: Quick tips on using a media advisory, pitch letter, news release, and public service announcement to encourage coverage
Talking Points for a PowerPoint Presentation: Key information for promoting a meeting, in presentation sequence
Key Facts: Talking points to use in raising awareness about underage drinking and its consequences
Customizable
Sample Panelist Invitation Letter: Template for inviting people to serve on a discussion panel
Sample Media Advisory: Template for alerting the media to your upcoming meeting
Sample Pitch Letter: Template for encouraging media coverage of your meeting
Sample News Release: Template for providing the media with complete information for their coverage of your meeting
Sample Poster/Flyer: Template for advertising your upcoming meeting
Handouts
Underage Drinking: Facts vs. Myths (2 pages)
Tips for Teens: The Truth About Alcohol (2 pages) [http://ncadi.samhsa.gov/govpubs/ph323]
Reach Out Now Family Pages (4 pages)
B
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The Surgeon General’s Call to Action To Prevent and Reduce Underage Drinking
The Surgeon General’s Call to Action To Prevent and Reduce Underage Drinking: What It Means to You—A Guide to Action for Communities
Llamado a la acción del Cirujano General para prevenir y reducir el consumo de alcohol por menores de edad: Lo que significa para usted—Guía de acción para las comunidades
The Surgeon General’s Call to Action To Prevent and Reduce Underage Drinking: What It Means to You—A Guide to Action for Families
Llamado a la acción del Cirujano General para prevenir y reducir el consumo de alcohol por menores de edad: Lo que significa para usted—Guía de acción para las familias
Focus on Prevention (Practical tips on engaging communities in underage drinking prevention)
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Federal Websites/Resources
Substance Abuse and Mental Health Services Administration (SAMHSA), http://www.samhsa.gov
SAMHSA’s Health Information Network, http://www.samhsa.gov/shin/
Too Smart To Start, http://www.toosmarttostart.samhsa.gov
National Institute on Alcohol Abuse and Alcoholism, http://www.niaaa.nih.gov
Alcohol Policy Information System, Highlight on Underage Drinking, http://www.alcoholpolicy.niaaa.nih.gov/index.asp?SEC={DA5E054D-FB8E-4F06-BBBC-6EED9F37A758}&Type=B_BASIC
The Cool Spot: The Young Teen’s Place for Info on Alcohol and Resisting Peer Pressure, http://www.thecoolspot.gov
College Drinking: Changing the Culture, http://www.collegedrinkingprevention.gov
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Who participated in the presentation at the THM event? (Mark all that apply)
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What are some of the major actions planned as a result of this THM event? (Mark all that apply)
Implementing social host ordinances
Forming SAFE HOMES Parents Networks
Creating underage drinking prevention action groups (e.g., committees, task forces, and advisory boards)
Starting a youth-led coalition on underage drinking prevention
Developing strategic plans to reduce and prevent underage drinking
Collaborating with other agencies or programs to reduce and prevent underage drinking
Planning additional THM events on underage drinking prevention
Planning other future events on underage drinking prevention
Holding follow-up meetings or discussion groups on underage drinking prevention
Applying for additional funding to sustain underage drinking prevention efforts
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Overall, how satisfied are you with this THM event?
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<Header: Town Hall Meetings on Underage Drinking Prevention: Organizers Survey>
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Did you participate in a THM-related Webinar?
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If yes, which Webinar did you participate in? (Mark all that apply.)
THM 101: How To Conduct Your First Town Hall Meeting on Underage Drinking Prevention
THM 201: Steps To Maximize Community and Media Support for Your Town Hall Meeting
How To Integrate Technology Into Your Town Hall Meeting Event
How To Plan and Maximize the Success of a Youth-Led Town Hall Meeting
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Did you view online training at www.stopalcoholabuse.gov?
(Continue to question 25) |
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If yes, which online training did you view? (Mark all that apply.)
How To Conduct a Town Hall Meeting
Cómo llevar a cabo un foro público capacitación
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Overall, how satisfied are you with the training you received?
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To what extent has the training you have received improved your capacity to provide effective (underage drinking) prevention services?
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To what extent have the training recommendations you received most recently been fully implemented?
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Did you request technical assistance (TA) in planning this THM event?
(Continue to question 30) |
(Skip to question 34) |
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<Header: Town Hall Meetings on Underage Drinking Prevention: Organizers Survey>
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If yes, how did you request the TA? (Mark all that apply.)
Called the THM technical assistance hotline (240–747–4980)
E-mailed [email protected]
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Overall, how satisfied are you with TA you received?
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To what extent has the TA you have received improved your capacity to provide effective (underage drinking) prevention services?
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To what extent have the TA recommendations you received most recently been fully implemented?
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Please share with us any other important features or reactions to the THM event.
Did your organization collect data about this THM event?
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If yes, would you be willing to share those data with SAMHSA?
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If yes, please submit the data along with a data codebook to the following address:
ICF Macro Attn.: THM on UAD - Rená A. Agee 11785 Beltsville Drive, Suite 300 Calverton, MD 20705 |
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If you have any questions about submitting data on this THM event, please e-mail [email protected] or call 240-747-4980.
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<Exit screen after DONE will say: Thank you again for sharing this important information about the Town Hall Meeting on Underage Drinking that was held in your community!>
| File Type | application/msword |
| File Title | Town Hall Meetings Question List (unformatted) |
| Author | Rena.A.Agee |
| Last Modified By | Rena.A.Agee |
| File Modified | 2010-09-27 |
| File Created | 2010-09-27 |