Form Participant Form_E Participant Form_E Participant Form_English

Attachment 2

Participant Form

O
MB 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 5 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: Participant Form

The purpose of this form is to obtain feedback on the Town Hall Meeting¹ on Underage Drinking Prevention event that was held in your community and to determine the intended or potential actions of community members following the event. This form will take about 5 minutes to complete. Your participation is completely voluntary. You can answer some or all of the questions. However, your answers are very important to us. Please do not write your name or other identifying information (e.g., birthday) anywhere on this form. Thank you!

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.

1. Date of Town Hall Meeting (THM) event: __________________

2. Location of THM event: City__________________ State/Territory__________________

3. Please indicate the most important underage drinking issue(s) facing your community.

(Mark all that apply.)

• Underage drinking and driving

• Alcopops

• Binge or high-risk drinking

• Underage alcohol use and risky behaviors

• Alcohol poisoning

• Lax parental attitudes toward underage drinking (e.g., parents allowing alcohol and parties in their homes; parents who see underage drinking as a harmless rite of passage)

• Lax enforcement of laws and local zoning ordinances

• Easy youth access to alcohol

• Lack of youth appeal to alcohol-free activities

• Alcohol advertising to which youth are exposed (in publications; on television, radio, and the Internet; and in outdoor and transit ads)

• Alcohol sponsorship of community events that appeal to youth (e.g., sports, cultural events, and music events)

• Other (please specify) _____________________________________________________________

4. To what degree do you think the THM event addressed the most important underage drinking issue(s) facing your community?

   A great deal

   Somewhat

   Not very much

   Not at all

5. Did you learn anything about underage drinking and its associated problems that you didn’t know before attending the THM event?

Yes

No

(Over)

6. Do you plan to share any material(s) or lessons learned from the THM event with others?

   Yes

   No

7. With whom do you plan to share the material(s) or lessons learned? (Mark all that apply.)

   My child/children	Friends
   Spouse	Coworkers
   Other relatives	Social organizations to which I belong
   Other youth	My place of employment
   Other parents of teens	Clergy
   Teachers	Other school/education staff
   Law enforcement	Education institutions
   Policymakers	Legislators
   Doctors	Other health care professionals
   Community leaders	Media contacts
   Youth leaders (e.g., coaches, parks and recreation personnel, and scouting leaders)	Other (please specify) _________________

8. Did you learn of specific ways in which you, as an individual, can help to prevent underage drinking?

Yes

No

9. How will you become more involved in working on decreasing underage drinking in your community? (Mark all that apply.)

• Join a coalition.

• Increase involvement in my local underage drinking prevention coalition.

• Participate in a SAFE HOMES Parents Network.

• Participate in followup meetings or discussion groups on underage drinking prevention.

• Participate in an underage drinking prevention action group (e.g., committee, task force, or advisory board).

• Contact my local legislators or policymakers to advocate legislation or policy changes or to recommend enhanced enforcement of existing laws and policies.

• Tell others about the dangers of underage drinking.

• Recommend that others attend future underage drinking prevention events or meetings.

• Other (please specify). ____________________________________________________________

• I do not think that I will become more involved in working on decreasing underage drinking in my community.

10. What is your gender?

    Male

    Female

11. How old are you?

• 12 to 17 years old

• 18 to 20 years old

• 21 to 24 years old

• 25 to 39 years old

• 40 to 55 years old

• 56 years old or older

12. Are you of Hispanic or Latino ethnicity?

    Yes

    No

13. What is your race? (Select one or more.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

14. Is there anything else you would like to tell us about this THM event? ___________________________________________________________________________________________________________________________________________________________________________________.

Thank you for sharing this important information about the THM event that was held in your community!

Please return this form to the event sponsor.

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.