Form Parents' Night Out Parents' Night Out Parents' Night Out Survey

Form Approved

OMB No. 0930-0197

Expiration Date: 02/28/2023

Thank you for agreeing to participate in this survey about the “Parents’ Night Out” presentation. Your responses will help SAMHSA improve its programs to assist families. The survey will take 5–7 minutes to complete. Your participation is voluntary, and you may quit or skip any question at any time. All of your answers will be kept strictly confidential. No individual results will be published; only summary information from all responses will be reported.

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 #0930-0197. Public reporting burden for this collection of information is estimated to average 7 minutes per respondent, 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, Carlos D. Graham, DHA, LCSW, LCAS at 5600 Fishers Lane, Room 15E57A, Rockville, MD, 20857.

1. Please provide your email to enter the survey. Your email will be used by the “Talk. They Hear You.” ® campaign for reminder purposes. Your email will be kept confidential and will not be used for any purpose other than occasional reminders about the “Parents’ Night Out” voluntary customer satisfaction survey.

[Text box]

2. Which “Parents’ Night Out” presentation did you attend? Please select from the following options: [A list of approved presentation dates.]

3. What was your top takeaway from the “Parents’ Night Out” presentation? [Open-ended essay box.]

4. Please state your level of agreement with the following statements about the presentation.

[Options will rotate.]

	Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
The materials in this presentation were presented in a logical way that helped me better understand the topics.
The presentation contained facts about underage drinking and other drug use I did not know before.
The public service announcement (PSA) was appropriate to the presentation/conversation.
The download process for the mobile app went smoothly.
I felt I had enough time to ask questions and get them answered during the presentation.

3. After attending the presentation, did it encourage you to plan to talk with your child/children about underage drinking and other drug use?

1. Yes, and as a result I have a firm plan and will talk with my child/children soon.

2. Yes, I have a vague plan, but need more information before I can talk with my child/children.

3. No, I do not have a plan, as I need more information.

4. No, I do not have a plan and I do not need more information.

3. If you needed more information on underage drinking and other drug use in order to talk to your kids about these topics, how would you get that information? [Please select all that apply.]

1. Watch videos on the “Talk. They Hear You.” campaign website at underagedrinking.samhsa.gov.

2. Use the “Talk. They Hear You.” campaign mobile app.

3. Read fact sheets, brochures, and/or other materials on the “Talk. They Hear You.” campaign website at underagedrinking.samhsa.gov.

4. Watch videos and/or obtain additional information from another website. Please describe: [Text box]

5. Talk to a school counselor or other school personnel.

6. Talk to a faith leader/member.

7. Talk to other parents/caregivers.

8. Other. Please describe:

3. [If participant answers 5a or 5b.] If you feel comfortable, would you share with us what you think you might say to your child/children about underage drinking and other drug use?

1. Yes

2. No

1. [If participant answers 7a] Please give us a brief summary of what you plan on saying to your child/children. [Essay text box]

3. The “Parents’ Night Out” presentation showcased a number of campaign resources, including informational videos and the mobile app. After the presentation, do you intend to: [Please select all that apply.] [Options will be rotated except for options h, i, and j.]

   1. Download the app, but not use it

   2. Download the app and use it to learn more about these issues

   3. Download the app and use it to practice conversations

   4. Visit the campaign website and watch additional videos

   5. Visit the campaign website and read additional materials

   6. Practice conversations on your own

   7. Visit the campaign YouTube channel

   8. Order campaign materials from the SAMHSA store

   9. Other: [Insert text box]

   10. Not take any actions

4. Please share any additional comments or suggestions you have about the “Parents’ Night Out” presentation. [Essay text box]

Demographic Section

3. What is your ZIP code? ____________________

4. Please indicate the age(s) of your child/children. Are they: [Please select all that apply.]

1. 9–11 years old

2. 12–14 years old

3. 15–17 years old

4. 18–20 years old

Thank you so much for your time. The “Talk. They Hear You.” campaign team will use your responses to improve the presentation. [Redirect to the underagedrinking.samhsa.gov website.]