Form Participant Form - Participant Form - Participant Form - English

Attachment 2

Participant Form (English version)

OMB No. 0930-0288

Approval Expires XX/XX/XXXX

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 # 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland 20857.

Communities Talk: Town Hall Meetings to Prevent Underage Drinking Participant Form

The purpose of this form is to obtain feedback on the Communities Talk: Town Hall Meetings¹ to Prevent Underage Drinking 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 # 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 Communities Talk event: __________________

2. Location of Communities Talk event:

City: _____________________ State/Territory: __________ ZIP Code: ____________

3. Please indicate how important it is to address the following underage drinking issues in your community:

	Very important	Moderately important	Not important
Underage drinking and driving
Powdered alcohol
Binge or harmful drinking
Risky behaviors associated with alcohol use
Alcohol poisoning
Lax parental attitudes toward underage drinking (e.g., parents who allow 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 appealing alcohol-free activities for youth
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., sporting events, cultural events, and music events)

Please list any other important underage drinking issues in your community not listed on the previous page.

1. _____________________________________________________________

2. _____________________________________________________________

4. To what degree do you think the 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 new about underage drinking and its associated problems that you didn’t know before attending the Communities Talk event?

   Yes

   No

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

   Yes

   No

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

   Yes

   No

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

My child/children	Friends
Other youth	My place of employment or coworkers
Spouse or other relatives	Social organizations to which I belong
Other parents of teens	Clergy
Teachers or other education staff	Community leaders
Law enforcement	Educational institutions
Legislators or policymakers	The media
Doctors or other health care professionals	Other (please specify): _________________
Youth leaders (e.g., coaches, parks and recreation personnel, and scouting leaders)

9. How often are you involved in underage drinking prevention in your community?

Always

Very often

Sometimes

Rarely

Never

10. After this event, do you think that you will become more involved in underage drinking prevention in your community?

Yes

No

11. For each statement below, please answer how likely you are to:

	Very likely	Somewhat likely	Not likely
Talk with others about underage drinking prevention.
Recommend that others attend future underage drinking prevention events or meetings.
Join, or increase involvement in, your local underage drinking prevention coalition.
Participate in follow-up 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 your local legislators or policymakers to advocate for changes to, or recommend enforcement of, existing laws and policies.
Support community organizations in their efforts to pass laws and policies to prevent underage drinking.

12. Please rate your agreement with the following statements:

	Strongly agree	Agree	Disagree	Strongly disagree
The Communities Talk event has increased my ability to share information and skills that prevent underage drinking.
The Communities Talk event has empowered me to help with underage drinking prevention in my community.
After the Communities Talk event, I feel better able to handle situations that involve underage drinking.
When confronted with underage drinking in my community, I am confident that I have the resources to address the issue or to get help.
Thanks to the Communities Talk event, I have learned ways to deal with peer pressure or other environmental influences that encourage alcohol use.

13. What is your sex?

    Male

    Female

14. 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

15. Are you of Hispanic or Latino ethnicity?

    Yes

    No

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

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

17. Is there anything else you would like to tell us about this Communities Talk event? __________________________________________________________________________________________________.

Thank you for sharing this important information about the

Communities Talk event that was held in your community!

Please return this form to the event sponsor.

1 Not all events are called Communities Talk: Town Hall Meetings (e.g., some events are called Community Forums); however, we will refer to them as Communities Talk for consistency in the data collection process.