Form Attachment 5-STOP Attachment 5-STOP Attachment 5-STOP Act State Survey

OMB No. 0930-xxxx
Expiration Date: xx/xx/xxxx
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-xxxx. Public reporting burden for this collection of
information is estimated to average xx 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.

STOP ACT STATE QUESTIONNAIRE
Part 1 - Enforcement

* Please Enter Your State Below:
GENERAL INSTRUCTIONS
This questionnaire represents one of several data collection efforts initiated by
the Secretary of HHS initiated pursuant to a Congressional directive found in
the Sober Truth on Preventing Underage Drinking (STOP) Act, (Pub. L. No.
109-422, § 2, 120 Stat. 2890 [2006]). The Act requires the Secretary to file an
annual report to Congress on the States’ progress in preventing and reducing
underage drinking. As stated in the STOP Act:
“The Secretary shall, with input and collaboration from other appropriate
Federal agencies, States, Indian tribes, territories, and public health, consumer,
and alcohol beverage industry groups, annually issue a report on each State's
performance in enacting, enforcing, and creating laws, regulations, and
programs to prevent or reduce underage drinking.”
The Act provides a list of specific underage drinking laws and policies, details
regarding their enforcement, and other programs that the Secretary should
include in the annual report. Federal data sources provide some of the data
requested. The questionnaire, which asks for the data requested by Congress,
provides States the opportunity to participate in the process and to insure
accurate and complete reporting.

PLEASE NOTE:
1) SAMHSA will report only the data you provide. Any question your State
does not answer will be reported as “no data available.”
2) To be included in the STOP Act report, this questionnaire must be
received by SAMHSA no later than XXX.
3) At the end of each section of the questionnaire, you will be asked to a
person whom we may contact if clarification is needed. This person will NOT
BE IDENTIFIED in any reports that result from this survey.
If you have questions or comments, please contact [SAMHSA CONTACT
PERSON].
Thank you in advance for your cooperation.
QUESTIONS DENOTED WITH AN ASTERISK (*) REQUIRE AN ANSWER FOR
THE SURVEY SKIP LOGIC TO OPERATE PROPERLY

PART I ENFORCEMENT: SECTION I.A - INTRODUCTORY QUESTIONS
A. 1 - Please identify the State agency/department that has PRIMARY
RESPONSIBILITY for ENFORCING laws designed to prevent underage
drinking (e.g., sales and/or furnishing of alcohol to minors, social host laws,
minor in possession, etc.).

A.2 - If applicable, please briefly describe how LOCAL AND STATE
enforcement agencies COORDINATE THEIR EFFORTS to enforce laws
prohibiting underage drinking.

A.3 - Do State or local law
enforcement agencies engage in any
of the following (see definitions):
Party
Underage
Cops Shoulder
Patrol
Alcoholin
Tap
Operations
Related
ShopsOperations
or
Fatality
Programs Investigations?
State g
c
d
e
f
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Local g
c
d
e
f
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g

* A.4 - Does your State collect data/maintain records on the number of
minors found in possession?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Don't Know

A.4 (Con't)
a - Based on readily available data, please provide estimates of how many
minors the State found in possession (or having consumed or purchased per
your State statutes) of alcohol during the most recent year for which
complete data are available.
Number of
Minors
Period for which data are reported
MM DD YYYY
12 Months
Ending:

/

/

b - Do the data provided above include arrests/citations issued by local law
enforcement agencies?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Don't Know

PART I ENFORCEMENT: SECTION I.B - SPECIFIC STATE AND LOCAL
UNDERAGE ENFORC...

The first set of questions in this section deals with UNDERAGE COMPLIANCE
CHECKS/DECOY OPERATIONS (see definition) at the STATE Level

* B.1 - Does your State Alcohol Agency conduct underage compliance

checks/decoy operations to determine whether alcohol retailers are
complying with laws prohibiting sales to minors? DO you collect data on
these activities?
Yes WE CONDUCT THESE ACTIVITIES, and WE COLLECT DATA on
them
j
k
l
m
n

Yes WE CONDUCT THESE ACTIVITIES, but we DO NOT collect data on
them
j
k
l
m
n
j
k
l
m
n

No, we neither conduct these activities nor collect data on them

j
k
l
m
n

Don't Know/No Answer

NOTE: A QUESTION ON STATE EXPENDITURES FOR COMPLIANCE
CHECKS/DECOY OPERATIONS WILL APPEAR IN SECTION IV OF THIS
QUESTIONNAIRE.

B.1 (Con't)
a - Based on readily available data, please provide estimates of the number
of licensees in your State upon which underage compliance checks/decoy
operations were conducted by your primary State alcohol law enforcement
agency. Please report on the most recent year for which you have complete
data.
Number of licensees upon which
underage compliance checks/decoy
operations were conducted (If you
do not collect these particular data,
please leave blank)
b - Based on readily available data, please provide estimates of the number
of licensees that failed these State compliance checks/decoy operations by
selling or serving an alcoholic beverage to an underage individual. Please
report on the most recent year for which you have complete data.
Total Number Who Failed (If you do
not collect these particular data,
please leave blank)

Period for which data are reported in B.1.a and B.1.b:
MM

DD
/

12 Months
Ending:

YYYY
/

This set of questions deals with UNDERAGE COMPLIANCE CHECKS/DECOY
OPERATIONS at the LOCAL Level

* B.2 - Do local law enforcement agencies conduct underage compliance
checks/decoy operations to determine whether alcohol retailers are
complying with these laws? Do you collect data on these activities?

j Yes local law enforcement conducts these activities and we collect data
k
l
m
n
on them

Yes local law enforcement conducts these activities, but we DO NOT
collect data on them
j
k
l
m
n
j
k
l
m
n

No, we neither conduct these activities nor collect data on them

j
k
l
m
n

Don't Know/No Answer

B.2 (Con't)
a - Based on readily available data, please provide estimates of the number
of licensees in your State upon which underage compliance checks/decoy
operations were conducted by local law enforcement agencies. Please
report on the most recent year for which you have complete data.
Number of licensees upon which underage
compliance checks/decoy operations were
conducted (If you do not collect these
particular data, please leave blank)
b - Based on readily available data, what was the TOTAL number of
licensees who failed the local compliance check/decoy operations by selling
or serving an alcoholic beverage to an underage individual for the most
recent year for which complete data are available?
Total umber of licensees who failed
(If you do not collect these particular
data, please leave blank)
Period for which data are reported in B.2.a and B.2.b:
MM
12 Months
Ending:

DD
/

YYYY
/

SECTION I.C - SANCTIONS
This section includes questions on sanctions imposed for retail furnishing of
alcohol to minors
Please provide data based on FINAL ADJUDICATIONS, not charges.

* C.1 -- Does your State collect data/maintain records on the NUMBER

and/or TOTAL AMOUNT of FINES imposed on retail establishments for
furnishing to minors?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Don't Know

C.1 (Con't) - Based on readily available data, please provide estimates of
the following over the last 12 month period for which complete data are
available. Do not include fines imposed by local agencies.
Enter a zero (0) if no fines were imposed in the 12 month period.

Number of Fines (If you do not collect
these particular data, please leave
blank)
Total Amount of Fines In Dollars
Across all Licensees (If you do not
collect these particular data, please
leave blank)
Period for which data are reported in C.1:
MM DD YYYY
12 Months
Ending:

/

/

* C.2 -- Does your state collect data on LICENSE SUSPENSIONS imposed on
retail establishments specifically for furnishing to minors?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Don't Know

C.2 (Con't) - Based on readily available data, please provide estimates of
the following over the last 12 month period for which complete data are
available. Do not include suspensions imposed by local agencies.
Enter a zero (0) if no suspensions were imposed in the 12 month period.

Number of Suspensions (If you do
not collect these particular data,
please leave blank)
Total Days of Suspensions Across all
Licensees (If you do not collect these
particular data, please leave blank)
Period for which data are reported in C.2:
MM DD YYYY
/
/
12 Months
Ending:

* C.3 -- Does your state collect data on LICENSE REVOCATIONS imposed on
retail establishments specifically for furnishing to minors?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Revocation is not an enforcement option in our state

j
k
l
m
n

Don't Know

C.3 (Con't) - Based on readily available data, please provide estimates of
the following over the last 12 month period for which complete data are
available. Do not include revocations imposed by local agencies.
Enter a zero (0) if no revocations were imposed in the 12 month period.

Number of
Rovocations
Period for which data are reported in C.3:
MM DD YYYY
/
/
12 Months
Ending:

SECTION I.D -- INTERNET SALES AND DIRECT SHIPPING
This section of questions deals with laws pertaining to INTERNET SALES AND
DIRECT SHIPPING of alcohol

D.1 - Does your State have a program to investigate and enforce the Direct
sales/shipment laws?
j
k
l
m
n

Don't Know

j
k
l
m
n

Yes

j
k
l
m
n

No

If yes, please identify the primary state agency responsible for enforcing
laws addressing direct sales/shipments of alcohol to minors.

D.2 - Are these laws also enforced by local law enforcement agencies?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Don't Know

Please use the space below to provide clarification of any of the information
provided in this section of the questionnaire.

Please provide the name and phone number or email of someone we can
contact for additional clarification if needed.
This person will NOT BE IDENTIFIED in any reports that result from this
survey.
Name
Phone
Number or
email
THANK YOU FOR YOUR PARTICIPATION

STOP ACT QUESTIONNAIRE - PART II - PROGRAMS
Pilot Test Version September 09

PART II: UNDERAGE DRINKING PREVENTION PROGRAMS
The STOP Act requires the Secretary of HHS to report on whether States have
"programs targeted to youths, parents, and caregivers to deter underage
drinking; and the number of individuals served by these programs.”
In this section of the survey, you will be asked to report on UNDERAGE
DRINKING PREVENTION PROGRAMS your State funds or operates.
NOTE: QUESTIONS WITH AN ASTERISK REQUIRE AN ANSWER IN ORDER
FOR THE SURVEY SKIP LOGIC TO WORK PROPERLY.

PART II A: SPECIFIC UNDERAGE DRINKING PREVENTION PROGRAMS
The first set of questions will ask about PROGRAMS THAT ARE SPECIFIC TO
UNDERAGE DRINKING -- i.e., that have prevention of underage drinking as
their PRIMARY OBJECTIVE.
Please use the following definitions in answering the questions in this section:

PLEASE INCLUDE ONLY THOSE PROGRAMS THAT YOUR STATE FUNDS OR
OPERATES DIRECTLY
Please DO include State funded or operated programs that serve as an
"umbrella" for local initiatives. In such cases, please describe the umbrella
program rather than the specifics of local activities.
Please DO NOT include programs or policies that have as their primary
objective the regulation of alcohol sales through State or Local licensing of
alcohol outlets.
Please NO NOT include general prevention programs that include underage
drinking prevention as one objectives but not the primary objective.

A.1) Please give the name of ONE program that your State OPERATES OR
FUNDS that is SPECIFIC TO UNDERAGE DRINKING PREVENTION as defined
above. You may also provide a brief description of the program, the number
of youth served by the program, the number of parents/caregivers served
by the program, and a URL where further information on the program may
be found.
You will be able to ADD ADDITIONAL PROGRAMS on the pages that follow.
Name of SPECIFIC Underage Drinking Prevention Program
Program Description

a - Based on your most recent annual data, please provide an estimate of
the number of youth served in this program.
If you do not collect these
particular data, please leave
this box blank

b - Based on your most recent annual data, please provide an estimate of
the number of parents (see definition above) served by this program.
If you do not collect these
particular data, please leave
this box blank
c - Based on your most recent annual data, please provide an estimate of
the number of caregivers (see definition above) served by this program.
If you do not collect these
particular data, please leave
this box blank
Period for which data are reported in A.1.a, A.1.b, and a.1.c above
MM DD YYYY
/
/
12 Months
Ending:
URL for More Information
Has this program been evaluated?
j
k
l
m
n

No

j
k
l
m
n

Yes, but there is no report available

j
k
l
m
n

Yes and there is a report available

Please provide URL or other source for report if available:

* Would you like to add another program that your State implements that is
SPECIFIC TO UNDERAGE DRINKING PREVENTION?
j
k
l
m
n

Yes

j
k
l
m
n

No

A.1 Con't) Please give the name of another program that your State
OPERATES OR FUNDS that is SPECIFIC TO UNDERAGE DRINKING
PREVENTION as defined above. You may also provide a brief description of
the program, the number of youth served by the program, the number of
parents/caregivers served by the program, and a URL where further
information on the program may be found.
You will be able to ADD ADDITIONAL PROGRAMS on the pages that follow.
Name of SPECIFIC Underage Drinking Prevention Program

Program Description

a - Based on your most recent annual data, please provide an estimate of
the number of youth served in this program.
If you do not collect these
particular data, please leave
this box blank
b - Based on your most recent annual data, please provide an estimate of
the number of parents (see definition above) served by this program.
If you do not collect these
particular data, please leave
this box blank
c - Based on your most recent annual data, please provide an estimate of
the number of caregivers (see definition above) served by this program.
If you do not collect these
particular data, please leave
this box blank
Period for which data are reported in A.1.a, A.1.b, and A.1.c above
MM DD YYYY
/
/
12 Months
Ending:
URL for More Information
Has this program been evaluated?
j
k
l
m
n

No

j
k
l
m
n

Yes, but there is no report available

j
k
l
m
n

Yes and there is a report available

Please provide URL or other source for report if available

* Would you like to add another program that your State implements that is
SPECIFIC TO UNDERAGE DRINKING PREVENTION?
j
k
l
m
n

Yes

j
k
l
m
n

No

A.1 Con't) Please give the name of another program that your State
OPERATES OR FUNDS that is SPECIFIC TO UNDERAGE DRINKING
PREVENTION as defined above. You may also provide a brief description of
the program, the number of youth served by the program, the number of
parents/caregivers served by the program, and a URL where further
information on the program may be found.
You will be able to ADD ADDITIONAL PROGRAMS on the pages that follow.
Name of SPECIFIC Underage Drinking Prevention Program
Program Description

a - Based on your most recent annual data, please provide an estimate of
the number of youth served in this program.
If you do not collect these
particular data, please leave
this box blank
b - Based on your most recent annual data, please provide an estimate of
the number of parents (see definition above) served by this program.
If you do not collect these
particular data, please leave
this box blank
c - Based on your most recent annual data, please provide an estimate of
the number of caregivers (see definition above) served by this program.
If you do not collect these
particular data, please leave
this box blank

Period for which data are reported in A.1.a, A.1.b, and A.1.c above
MM DD YYYY
12 Months
Ending:

/

/

URL for More Information
Has this program been evaluated?
j
k
l
m
n

No

j
k
l
m
n

Yes, but there is no report available

j
k
l
m
n

Yes and there is a report available

Please provide URL or other source for report if available

* Would you like to add another program that your State implements that is
SPECIFIC TO UNDERAGE DRINKING PREVENTION?
j
k
l
m
n

Yes

j
k
l
m
n

No

THE ABOVE QUESTIONS WILL BE ITERATED TO ALLOW UP TO 20 PROGRAMS
TO BE ENTERED

****NOTE TO TEAM: GIVEN SPACE FOR 20 PROGRAMS ABOVE, DO WE NEED
THIS?*****
A.2) If you have additional programs that your State OPERATES OR FUNDS
that are SPECIFIC TO UNDERAGE DRINKING PREVENTION as defined
above, please identify them below with the program names,URLs if
available, and a brief description of the programs.

Names, URLs, Brief Descriptions

PART II B: RELATED UNDERAGE DRINKING PREVENTION PROGRAMS
The next set of questions will ask about PROGRAMS THAT ARE RELATED TO
UNDERAGE DRINKING.
Programs RELATED to underage drinking are those that address other drug
use (including tobacco) IN ADDITION TO alcohol use. Examples may include:
o School-based drug and alcohol education
o Programs that address individual risk and protective factors
o Programs to strengthen families
Please use the following definitions in answering the questions in this section:

PLEASE INCLUDE ONLY THOSE PROGRAMS THAT YOUR STATE FUNDS OR
OPERATES DIRECTLY
Please DO include State funded or operated programs that serve as an
"umbrella" for local initiatives. In such cases, please describe the umbrella
program rather than the specifics of local activities.
Please DO NOT include programs that are not, in some way, related to
underage alcohol use.

B.1) Please give the name and URL of ONE program that your State
OPERATES OR FUNDS that is RELATED TO UNDERAGE DRINKING
PREVENTION as defined above.
You will be able to ADD ADDITIONAL PROGRAMS on the pages that follow.
Name of RELATED Underage Drinking Prevention Program
URL for More Information

* Would you like to add a another program that your State implements that is
RELATED TO UNDERAGE DRINKING PREVENTION?
j
k
l
m
n

Yes

j
k
l
m
n

No

B.1 Con't) Please give the name and URL of another program that your
State OPERATES OR FUNDS that is RELATED TO UNDERAGE DRINKING
PREVENTION as defined above.
You will be able to ADD ADDITIONAL PROGRAMS on the pages that follow.
Name of RELATED Underage Drinking Prevention Program
URL for More Information

* Would you like to add another program that your State implements that is
RELATED TO UNDERAGE DRINKING PREVENTION?
j
k
l
m
n

Yes

j
k
l
m
n

No

ABOVE QUESTIONS ITERATED TO ALLOW UP TO 20 PROGRAMS TO BE
ENTERED

PART II C: UNDERAGE DRINKING PREVENTION PROGRAMS
ADDITIONAL QUESTIONS

* C.1) Does your State collaborate with Federally Recognized Tribal
Governments in the prevention of underage drinking?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

There are no Federally Recognized Tribal Governments in this State

Question C.1 Con't)
a) In the space provided below, please briefly describe these collaborations.

* C.2 Does your State have programs to measure and/or reduce youth
exposure to alcohol advertising and marketing?
j
k
l
m
n

Yes

j
k
l
m
n

No

Question C.2 Con't)
a) In the space provided below, please briefly describe these programs.

* C.3) Has your State adopted or developed best practice standards for
Underage Drinking Prevention Programs?
j
k
l
m
n

Yes

j
k
l
m
n

No

Question C.3 (Con't)
a) In the space provided below, please describe your State's Best Practice
Standards

Please use the space below to provide clarification of any of the information
provided in this section of the questionnaire

Please provide the name and phone number or email of someone we can
contact for additional clarification if needed.
This person will NOT BE IDENTIFIED in any reports that result from this
survey.
Name
Phone
Number or
Email
THANK YOU FOR YOUR PARTICIPATION

STOP ACT QUESTIONNAIRE PART III - COLLABORATIONS
Pilot Test Version - September 09

PART III: STATE INTERAGENCY COLLABORATION
In this section, please provide information on interagency collaboration to
reduce underage drinking.
NOTE: QUESTIONS WITH AN ASTERISK REQUIRE AN ANSWER FOR THE
SURVEY SKIP LOGIC TO OPERATE PROPERLY.

* 1) Is there a State-level interagency governmental body/committee that
coordinates or addresses underage drinking prevention activities in your
State?
j
k
l
m
n

Yes

j
k
l
m
n

No

j
k
l
m
n

Don't Know/No Answer

Question 1 (Con't)
a) Please provide a Committee contact (the Chair of the Committee or other
primary contact person) in the space below as well as her/his email,
address, and phone number.
Name
Email
Address
Phone

b) Please list the agencies/organizations represented on the committee. If
more than ten agencies/organizations are represented, use the additional
space below
Agency/Organization
Agency/Organization
Agency/Organization
Agency/Organization
Agency/Organization
Agency/Organization
Agency/Organization
Agency/Organization
Agency/Organization
Agency/Organization
Additional Agencies/Organizations

* c) Is there a website or other public source that describes the committee’s
activities?
j
k
l
m
n

Yes

j
k
l
m
n

No

Please provide a website address or other means to access this information.

* 2) Has your State prepared a plan for preventing underage drinking in the
last 3 years?
j
k
l
m
n

Yes

j
k
l
m
n

No

Question 2 (Con't)
a) What agency, committee, or other body prepared the plan?

b) If available, please provide a website address or other means to access
the plan

* 3) Has your State prepared a report on underage drinking in the last 3
years?
j
k
l
m
n

Yes

j
k
l
m
n

No

Question 3 (Con't)
a) What agency, committee, or other body prepared the report?

b) If available, please provide the website address or other means to
access the report.

Please use the space below to provide clarification of any of the information
provided in this section of the questionnaire.

Please provide the name and phone number or email of someone we can
contact for additional clarification if needed.
This person will NOT BE IDENTIFIED in any reports that result from this
survey.
Name
Phone
Number or
Email
THANK YOU FOR YOUR PARTICIPATION

STOP ACT QUESTIONNAIRE PART IV - STATE EXPENDITURES
Pilot Test Version -- September 09

PART IV: STATE EXPENDITURES FOR PREVENTION OF UNDERAGE
DRINKING
This section requests estimates of the funds expended annually by your State
specifically for the prevention of underage drinking under a variety of headings
specified in the STOP Act.
For each activity or program listed on the following pages, please provide an
estimate of the STATE FUNDS your State expended during the most recent
year for which complete data are available.
If you do not have access to relevant data, please check "These Data are
Not Available in My State."
Please DO NOT include Federal, local, or private funding sources.
Please Note: The STOP Act requires the Secretary of HHS to report PER
CAPITA expenditures. The calculation of per capita rates will be made
during the analysis of the survey using census data.

SECTION A: STATE EXPENDITURES
A.1) COMPLIANCE CHECKS/DECOY OPERATIONS IN RETAIL OUTLETS
including provision of TECHNOLOGY TO DETECT AND PREVENT THE USE OF
FALSE IDENTIFICATION BY MINORS.
Please consider only those Compliance Checks/Decoy Operations that your
State FUNDS OR OPERATES DIRECTLY.

Can't Answer This Question
j
k
l
m
n

These Data are Not Available in My State

Estimate of State Funds Expended
Dollars per 12 Month
Period

Period for which data are reported
MM DD YYYY
/

12 Months
Ending

/

A.2) CHECKPOINTS AND SATURATION PATROLS that include the goal of
reducing and deterring underage drinking.
Please consider only those Checkpoints and Saturation Patrols that your State
FUNDS OR OPERATES DIRECTLY.
Can't Answer This Question
j
k
l
m
n

These Data are Not Available in My State

Estimate of State Funds Expended
Dollars per 12 Month
Period
Period for which data are reported
MM DD YYYY
/
/
12 Months
Ending

A.3) COMMUNITY-BASED programs to prevent underage drinking,
Please consider only those Community-Based Programs that your State FUNDS
OR OPERATES DIRECTLY.
Can't Answer This Question
j
k
l
m
n

These Data are Not Available in My State

Estimate of State Funds Expended
Dollars per 12 Month
Period
Period for which data are reported
MM
12 Months
Ending

DD
/

YYYY
/

A.4) K-12 SCHOOL-BASED programs to prevent underage drinking.

Please consider only those K-12 School-Based Programs that your State FUNDS
OR OPERATES DIRECTLY
Can't Answer This Question
j
k
l
m
n

These Data are Not Available in My State

Estimate of State Funds Expended
Dollars per 12 Month
Period
Period for which data are reported
MM
12 Months
Ending

DD
/

YYYY
/

A.5) Programs to prevent underage drinking targeted at INSTITUTIONS OF
HIGHER EDUCATION.
Please consider only those Higher Education Programs that your State FUNDS
OR OPERATES DIRECTLY.
Can't Answer This Question
j
k
l
m
n

These Data are Not Available in My State

Estimate of State Funds Expended
Dollars per 12 Month
Period
Period for which data are reported
MM DD YYYY
/
/
12 Months
Ending

A.6) Underage drinking prevention programs that target youth within the
JUVENILE JUSTICE SYSTEM.
Please consider only those Juvenile Justice System Programs that your State
FUNDS OR OPERATES DIRECTLY.
Can't Answer This Question
j
k
l
m
n

These Data are Not Available in My State

Estimate of State Funds Expended
Dollars per 12 Month
Period
Period for which data are reported
MM
12 Months
Ending

DD
/

YYYY
/

A.7) Underage drinking prevention programs that target youth within the
CHILD WELFARE SYSTEM.
Please consider only those Child Welfare System Programs that your State
FUNDS OR OPERATES DIRECTLY.
Can't Answer This Question
j
k
l
m
n

These Data are Not Available in My State

Estimate of State Funds Expended
Dollars per 12 Month
Period
Period for which data are reported
MM DD YYYY
/
/
12 Months
Ending

A.8) Please provide an estimate of the STATE FUNDS your State expended
during the most recent year for which complete data are available for any
programs or strategies OTHER THAN THOSE LISTED ABOVE.
Please consider only those programs or strategies that your State FUNDS OR
OPERATES DIRECTLY.
Programs or Strategies Included (Please list):
Estimate of State Funds Invested
Dollars per 12 Month
Period

Period for which data are reported
MM DD YYYY
/

12 Months
Ending

/

SECTION B: ADDITIONAL QUESTIONS
B.1) Are funds dedicated to underage drinking derived from any of the
following revenue streams in your State?
Yes
No
Taxes
j
k
l
m
n
j
k
l
m
n
Fines
Fees

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other (please specify)

If you answered yes to any of the above, please briefly describe these
funding streams and how they are used.

Please use the space below to provide clarification of any of the information
provided in this section of the questionnaire

Please provide the name and phone number or email of someone we can
contact for additional clarification if needed.
This person will NOT BE IDENTIFIED in any reports that result from this
survey.
Name
Phone
Number or
Email
THANK YOU FOR YOUR PARTICIPATION