Attachment 1
Organizer Survey
<Opening Page>
OMB No. 0930-0288
Approval Expires 11/30/2013
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 0930-0288. 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 7-1044, Rockville, Maryland 20857.
Town Hall Meetings on Underage Drinking Prevention: Organizer Survey
INFORMED CONSENT STATEMENT
Congratulations on your participation in the Town Hall Meetings1 (THMs) on Underage Drinking Prevention initiative! You may recall that, as a participant in the THMs initiative, your organization agreed to complete a survey regarding the THM event that was held in your community. The information collected will be used by the Substance Abuse and Mental Health Services Administration (SAMHSA) to document the implementation efforts of this nationwide initiative and to enhance future THM events. The survey will take about 20 minutes to complete.
It is important to obtain information from a large number of organizations to maintain quality of service. The information you provide will not be associated with your or your organization’s name in any reports or data given to SAMHSA. If you have any questions or concerns about participating in this survey, please e-mail [email protected] or call the THM information line at (866) 419–2514.
By continuing, you are consenting to participate in this survey 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.
<Header: Town Hall Meetings on Underage Drinking Prevention: Organizer Survey> Page 1 of 4
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.
Date of Town Hall Meeting (THM) event: MM/DD/YYYY
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(Continue through WY + territory codes)
How would you characterize the location where the THM event was held?
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How long did the THM event last? # hours # minutes
Did any other community-based organization (e.g., business, school) collaborate with your organization/coalition in hosting this event?
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Were youth involved in organizing and/or hosting the THM event?
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Was underage drinking the only topic addressed by the THM event?
(Skip to question 9) |
(Continue to question 8) |
If no, what other topics were discussed?
How was the THM event promoted in the community? (Mark all that apply.)
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<Header: Town Hall Meetings on Underage Drinking Prevention: Organizer Survey> Page 2 of 4
What was the total number of THM event attendees? (Estimates are okay.)
# of physical attendees: # of virtual attendees:
In what language(s) was(were) the THM event conducted? (Mark all that apply.)
English
Spanish
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Which of the following best represents key speakers at the THM event? (Mark all that apply.)
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Which of the following topics were discussed at the THM event? (Mark all that apply.)
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Did you use any material(s) from www.stopalcoholabuse.gov for the THM event?
(Continue to question 15) |
(Skip to question 16) |
If yes, what material(s) did you use?
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<Header: Town Hall Meetings on Underage Drinking Prevention: Organizer Survey> Page 3 of 4
What underage drinking prevention activities are planned as a result of this THM event? (Mark all that apply.)
Implementing social host ordinances
Forming SAFE HOMES Parents Networks
Creating underage drinking prevention action groups (e.g., committees, task forces, and advisory boards)
Starting a youth-led coalition on underage drinking prevention
Developing strategic plans to reduce and prevent underage drinking
Collaborating with other agencies or programs to reduce and prevent underage drinking
Planning additional THM events on underage drinking prevention
Planning other future events on underage drinking prevention
Holding followup meetings or discussion groups on underage drinking prevention
Applying for additional funding to sustain underage drinking prevention efforts
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Overall, how satisfied are you with this THM event?
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Did you participate in a THM-related webinar?
(Continue to question 19) |
(Skip to question 20) |
If yes, which webinar did you participate in?
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Did you view online training at www.stopalcoholabuse.gov?
(Continue to question 21) |
(Skip to question 24; if answered Yes to question 18, skip to question 22) |
If yes, which online training did you view?
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Please respond to the following statements regarding the training received (through a webinar or online training).
The training has been useful to my organization’s prevention work.
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The training I received improved my organization’s capacity to do prevention work.
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<Header: Town Hall Meetings on Underage Drinking Prevention: Organizer Survey> Page 4 of 4
Did you receive technical assistance in planning this THM event?
(Continue to question 25) |
(Skip to question 28) |
How did you submit the request for technical assistance? (Mark all that apply.)
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Please respond to the following statements regarding the technical assistance received in planning this THM event.
The technical assistance has been useful to my organization’s prevention work.
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The technical assistance has improved my organization’s capacity to do prevention work.
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Please share with us any other important features or reactions to the THM event.
Did your organization collect data about this THM event?
(Continue to question 30) |
(Proceed to the end and click done) |
If yes, would you be willing to share those data with SAMHSA?
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If yes, please submit the data along with a data codebook to the following address:
ICF
Attn.: THM on UAD—Rená A. Agee
11785 Beltsville Drive, Suite 300, Calverton, MD 20705
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<Exit screen after DONE will say: Thank you again for sharing this important information about the Town Hall Meeting on Underage Drinking that was held in your community!>
1 Not all events are called Town Hall Meetings (e.g., Community Forums); however, we will refer to them as Town Hall Meetings (THMs) for consistency in the data collection process.
| File Type | application/msword |
| File Title | Town Hall Meetings Question List (unformatted) |
| Author | Rena.A.Agee |
| Last Modified By | Rena.A.Agee |
| File Modified | 2013-05-23 |
| File Created | 2013-05-23 |