D Form D Follow-Up Form For Community Event Participant 7-

Form D: Feedback Form for Community Event Participants

(Completed Four Months After the Initial Community Event)

You attended an event about four months ago that was convened by __(organization/contact person)________________ to share information about the issue of bullying among youth and what can be done to prevent it.

We are interested in your feedback on the information and resources that were shared at this event and would like to know what further actions you, or the organization that you work for or represent, may have taken in support of this community initiative.

Background Information

1. Please select the sector that best describes the organization you are primarily affiliated with.

 Elected officials and government  Educators	 City/county recreation  Parents and caregivers
 Health and safety professionals  Law enforcement officials  Mental health and social services professionals Faith-based	 Corporate and business professionals  Child care/after school & out-of-school care professionals  Youth leaders organizations
 Other (describe)

2. Do you currently live and/or work in the target area for the bullying prevention event and initiative?

 Yes, I live and work in the target area

 I live outside of the target area, but my work covers this area

 No, I live and work outside of the target area

Activities Following the Initial Community Event

3. To your knowledge, have there been follow-up initiatives or activities in your community that have focused on the issue of bullying among children and youth?

____ Yes

____ No (If no, skip to question 9)

4. Please describe the nature of any follow-up initiative or activities in your community.

5. Were these initiatives or activities coordinated by a group or a coalition?

____ Yes - Name:________________

____ No

____ I’m not sure

6. Have you (or the group/agency you represent) participated in any of these initiatives or activities?

____ Yes

____ No

7. If you answered yes to question 6, please describe roles you or your organization played in these initiatives or activities. (Select all that apply.)

 Recruited participants, sponsors or partnering agencies for subsequent activities

 Helped to plan another awareness-raising event

 Joined the coalition/group that is planning the community prevention initiative

 Contributed time, materials or financial resources to the initiative

 Other (describe) ________________________________________________

 Other (describe) ________________________________________________

8. If you answered yes to question 5, how would you characterize the work of this group/coalition’s bullying prevention initiative? Rate the following qualities as not at all true to very true.

The planning group/coalition…	Not at all true	Some-what true	Very True
Facilitates group communications and consensus-building with respect and inclusiveness	1	2	3
Reaches out and draws in a diverse and committed group of stakeholders & community leaders	1	2	3
Maximizes the strengths of individuals and agencies in assigning tasks	1	2	3
Sets clear objectives and action steps	1	2	3
Organizes efficient meetings and well-managed events	1	2	3
Collects and uses data to inform decisions, and constantly improve strategies and outcomes	1	2	3

9. How have you, or your group/agency, applied the information you gained at the initial community event to your work?

10. What additional information and resources are needed to proceed with next steps in implementing prevention plans and strategies in your community?

Thank you for taking the time to provide feedback!

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 0915-0212. Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857.

3

3

Approved OMB # 0915-0212 Exp. Date 07/31/2015