Form J Brand Ambassador Implementation Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Attachment J:

Brand Ambassador Implementation Survey

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Survey Date:

Site number:

Program Year:

Survey Iteration:

Brand Ambassador Implementation Survey

In addition to the below questions, informal qualitative feedback will be a helpful/important supplement. Since we have yet to determine the Brand Ambassador Program name, we have used YY as a placeholder, which should not impact OMB.

Site:

1. To what extent do you agree or disagree with the following statements?

	Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
A) The training was informative.
B) The training was engaging.
C) The adult program supervision was helpful.
D) The YY was worthwhile.
E) YY was effective in promoting the campaign messages
F) I would recommend participating in the brand ambassador program to my friends.

2. What did you enjoy most/least about the program?

3. What would you have liked to have done more/less of?

4. Which activities were most/least successful?

5. What could be done to improve the program?

6. How much time did you spend on Brand Ambassador activities over the past school year?

Brand ambassadors collect the following cost information:

• How much time did you spend on Brand Ambassador activities over the past 3 months?