Attachment 1
State/Territory Videos Project – Point of Contact Feedback Form
<Opening Page>
OMB No. 0930-XXXX
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‑XXXX. Public reporting burden for this collection of information is estimated to average 20 minutes 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 8-1099, Rockville, Maryland, 20857.
State/Territory Videos Project – Point of Contact Feedback Form
INFORMED CONSENT STATEMENT
Congratulations on your participation in the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention (SAMHSA/CSAP) State/Territory Videos project! You may recall that, as a participant in this project, you agreed to provide feedback on the experience of your State/Territory with producing the underage drinking prevention video. The information collected on this feedback form will be used by SAMHSA/CSAP to ascertain whether the videos are assisting States/Territories in communicating effectively about their underage drinking prevention initiatives, goals, and objectives; document the dissemination efforts of the video; and enhance the technical assistance that is provided by the video production team in producing the videos.
This feedback form will take approximately 20 minutes to complete. It is important to obtain information from all participants in the State/Territory Videos project to maintain quality of service. The information you provide will not be associated with your name or your State/Territory in any reports to SAMHSA/CSAP. The findings reported to SAMHSA/CSAP will be in group form. Information provided on this feedback form (e.g., respondent identifiers and dissemination information) may be shared with the production team to improve service delivery and to update the dissemination plans identified in the outline for your State’s/Territory’s video. If you have any questions or concerns about completing this feedback form, please email XXX or call (XXX) XXX-XXXX.
By continuing, you are consenting to provide feedback 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.
[Programmer → Auto capture feedback form completion date.]
<Header: State/Territory Videos Project – Point of Contact Feedback Form>
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Please answer each question by marking one of the answer choices. Some questions allow you to mark more than one answer. If you don’t find an answer that fits exactly, choose the one that comes closest.
Please describe at least two of the objectives for your State’s/Territory’s video on underage drinking prevention.
Objective 1:
Objective 2:
What are the video’s target audiences? (Mark all that apply.)
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The next questions are about the dissemination efforts of the State/Territory video product.
Has the video been disseminated?
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[Programmer → If response to q3 = Yes, program to ask →] Please indicate how the video was disseminated from the categories listed below and provide dissemination numbers (e.g., # of views/downloads, viewers or copies distributed) for each category utilized. (Mark all that apply.) |
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<Header: State/Territory Videos Project – Point of Contact Feedback Form>
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[Programmer → If response to q3 = No, program to ask →] When do you plan to disseminate the video? _______________________________________ |
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Which of the following is among the dissemination plans for the video? (Mark all that apply.) |
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4. Have you encountered any challenges and/or limitations in disseminating the video?
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5. What challenges and/or limitations have you encountered?
6. How were the challenges and/or limitations resolved?
[Programmer → if q3 = No and q4 = Yes, auto skip to q9]
7. Have you received any feedback on the reaction of audiences who have been exposed to the video?
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8. What is the nature of the feedback and who provided the feedback?
9. Have there been any unintended outcomes from either making or disseminating the video?
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10. Please describe the unintended outcomes.
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<Header: State/Territory Videos Project – Point of Contact Feedback Form>
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The next questions are about your perceptions of the State/Territory video product.
11. In your opinion, what effect does the video have on the capacity of your State/Territory to communicate about its underage drinking prevention activities?
12. In your opinion, what effect does the video have on the capacity of your State/Territory to help raise awareness about the underage drinking prevention successes among the targeted audiences in your State/Territory?
13. In your opinion, what effect does the video have on the capacity of your State/Territory to help raise awareness about the underage drinking prevention challenges among the targeted audiences in your State/Territory?
The next questions are about the technical assistance your State/Territory received in producing the video product.
14. How useful did you find the following preplanning materials and activities:
Please mark your response by placing an X in the box. |
Very useful |
Somewhat useful |
Not useful |
Informative emails |
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Frequently Asked Questions (FAQs) |
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Conference calls |
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Produce an Effective Underage Drinking Prevention Video: A Guide to the Video Production Process |
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Quarterly e-newsletter |
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15. Did you encounter any challenges and/or limitations in developing the video?
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16. What challenges and/or limitations did you encounter?
17. How were the challenges and/or limitations in developing the video resolved?
18. If technical assistance (TA) was provided by the video production team, what effect did it have on the challenges and/or limitations encountered?
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<Header: State/Territory Videos Project – Point of Contact Feedback Form>
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19. How helpful would you rate the TA provided by the video production team during the following activities:
Please mark your response by placing an X in the box. |
Very helpful |
Somewhat helpful |
Not helpful |
Pre-Production phase |
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Field Production (on-site shooting) phase |
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Post-Production phase |
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20. Overall, how satisfied are you with the TA your State/Territory received [from the video production team]?
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21. To what extent has the TA you received [from the video production team] improved your State’s/Territory’s capacity to provide effective (underage drinking) prevention services?
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22. To what extent have the TA recommendations your State/Territory received most recently [from the video production team] been fully implemented?
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23. What would you recommend to improve the video development process used to create your State’s/Territory’s video?
24. What advice would you give to other States/Territories that are interested in producing a video on underage drinking prevention?
25. Is there anything else that you would like to tell me about the video production support or video product for your State/Territory?
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[Programmer → code Exit screen after DONE to say: Thank you again for sharing this important information about your State’s/Territory’s experience with producing the underage drinking prevention video. You will be contacted in about 6 months to update the dissemination efforts of your State’s/Territory’s video.]
| File Type | application/msword |
| File Title | WebCast Feedback Questions |
| Author | Sandra.S.Chipungu |
| Last Modified By | Sharon Harrison |
| File Modified | 2011-10-27 |
| File Created | 2011-10-27 |