Form Participant Form - Participant Form - Participant Form - English

Assessment of the Underage Drinking Prevention Initiative

Attachment 2 - Participant Form_English Version_10-13-16

Participant Form

OMB: 0930-0288

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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: ____________

  1. 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. _____________________________________________________________

  1. 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

  2. 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

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

    • Yes

    • No

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

    • Yes

    • No

  5. 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)


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


  • Always

  • Very often

  • Sometimes

  • Rarely

  • Never


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

  • Yes

  • No


  1. 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.


  1. 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.


  1. What is your sex?

    • Male

    • Female

  2. 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

  1. Are you of Hispanic or Latino ethnicity?

    • Yes

    • No

  2. 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

  1. 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.

File Typeapplication/msword
File TitleTown Hall Meetings Question List (unformatted)
AuthorRena.A.Agee
Last Modified ByZurla, Christina
File Modified2016-10-13
File Created2016-10-13

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