Attachment 2
Participants 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 .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
INFORMED CONSENT STATEMENT
Thank you for participating in the Town Hall Meeting (THM) on Underage Drinking Prevention event that was held in your community! To improve future THM events and find out how successful the THM events were across the nation, the Substance Abuse and Mental Health Services Administration (SAMHSA) needs your help.
You are being asked to complete a short survey about the THM event that was held in your community. Your participation in the survey is completely voluntary. Taking the survey will cause little or no risk to you. The only possible risk is the discomfort that is connected with completing any survey. The survey will take about 10 minutes to complete. You can choose to answer all or some of the questions. You can also stop taking the survey at any time.
Your answers to the questions will be kept private to the extent of the law and will not be linked with your name in any reports to SAMHSA. 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 agree to participate in this survey. If you are under the age of 18, by continuing you agree that you have received your parent’s/caregiver’s permission to participate in this survey.
Continue
Cancel
NOTE: As you complete each page of the survey and click NEXT, data entered will be automatically saved. You will NOT be able to return to the survey you completed once you click DONE or if you exit the survey.
<Header: Town Hall Meetings on Underage Drinking Prevention: Participants Survey>
Page 1 of 4
Date of Town Hall Meeting (THM) event: MM/DD/YY
L
AL
AK
AS
AZ
(Continue through WY + Territory codes)
About how many people do you think attended the THM event?
Less than 50
Between 50 and 150
Between 150 and 300
Over 300
Did you learn anything about underage drinking and its associated problems that you didn’t know before attending the THM event?
Yes
No
Have you shared with others any material(s) or lessons learned from the THM event?
Yes
No
With whom did you share the material(s) or lessons learned? (Mark all that apply.)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Next
Cancel
<Header: Town Hall Meetings on Underage Drinking Prevention: Participants Survey>
Page 2 of 4
Do you think you will become more involved in working on decreasing underage drinking in your community?
Yes
No
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
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
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
Back
Next
Cancel
<Header: Town Hall Meetings on Underage Drinking Prevention: Participants Survey>
Page 3 of 4
The THM event was appropriate in length and duration.
Strongly agree
Agree
Disagree
Strongly disagree
Overall, the presenters were knowledgeable in the areas covered at the THM event.
Strongly agree
Agree
Disagree
Strongly disagree
Overall, the THM event was well planned and executed.
Strongly agree
Agree
Disagree
Strongly disagree
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
What is your gender?
Male
Female
Transgender:
Male to female
Female to male
O
Are you of Hispanic or Latino ethnicity?
Yes
N
Back
Next
Cancel
<Header: Town Hall Meetings on Underage Drinking Prevention: Participants Survey>
Page 4 of 4
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
Back
Done
Cancel
<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 |