Form Attachment 3 Attachment 3 Video Viewers Feedback Form

Attachment 3

Video Viewers Feedback Form

Video Viewers Feedback Form

INFORMED CONSENT STATEMENT

The Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Prevention (SAMHSA/CSAP) sponsors a video series that highlights underage drinking prevention initiatives conducted throughout the United States and its Territories. The purpose of this form is to obtain feedback about your views of underage drinking as a public health issue prior to and after watching one of the State/Territory videos. This form will take about 5 minutes to complete. Please complete one form for each video that you watched. Although your feedback is important to us, your participation is completely voluntary and you can choose to answer some or all of the questions. Please do not include your name or contact information anywhere on this form. Information collected on the feedback forms will be combined in study reports to SAMHSA/CSAP. If you have any questions and/or concerns about completing this form, please email XXX or call (XXX) XXX-XXXX.

By continuing, you are consenting to complete this feedback form. If you are under the age of 18: By continuing, you are stating that you have received permission from a parent/guardian to complete this feedback form. Thank you for taking the time to provide this feedback.

Continue

Cancel

Please select your best response(s) for each question.

1. Which State/Territory video did you watch? __________________________________

2. Please select your best response by placing an X in the box.

	Very Concerned	Somewhat Concerned	Not Concerned
Prior to watching this video, how would you describe your level of concern with underage drinking as a public health issue?
As a result of watching this video, how would you describe your level of concern with underage drinking as a public health issue?

3. As a result of watching this video, do you plan to seek information about underage drinking?

Yes

No

4. As a result of watching the video, how, if at all, do you plan to become involved in underage drinking prevention efforts? (Mark all that apply.)

• I do not think that I will become involved in underage drinking prevention efforts.

• Talk with my child/family/friends about the dangers of underage drinking.

• Alter/change personal practices related to serving alcohol and alcohol consumption.

• Join a coalition or organization working to prevent and reduce underage drinking.

• Contact policy and lawmakers to advocate for changes and/or recommend enhanced enforcement of existing laws and policies.

• Other (Please specify) _________________________________

5. To whom, if anyone, would you recommend this video? (Mark all that apply.)

I would not recommend the video	Coworkers
Parents/Relatives	Youth
Caregivers	Academic/Community/Social Organizations
Educators	Youth Leaders (e.g., coaches, scouting leaders)
Law Enforcement	Media Professionals
Government Officials	O ther (Please specify)
Health Care Professionals
Friends

6. Please let us know why you would or would not recommend the video.

Demographic Information: Please select your best response(s) for each question.

What is your gender?

• Male

• Female

How old are you? (Select the most appropriate category.)

under 12 years old	21 to 24 years old
12 to 14 years old	25 to 44 years old
15 to 17 years old	45 to 64 years old
18 to 20 years old	65 years old or older

What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

What is your race? (Mark one or more race.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

Cancel

Done

Back

[

Back

Done

Cancel

Programmer → Code Exit screen after DONE to say: Thank you for providing feedback on underage drinking prevention video that you watched!]