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Second Decade Community Planning Guide - Coalition Assessment Survey

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

The following survey is intended to gather information about your experiences participating in the Coalition for the Second
Decade Project Community Planning Guide. Your feedback and recommendations for improving the Guide will help the
Office of the Assistant Secretary of Health (OASH) and others who work with youth 10-19 years of age. Your thoughtful
participation is appreciated.
Before you complete this survey, please read the following consent form. The survey will take approximately 15
minutes. By completing and submitting this web survey, you are consenting to participate. Your participation in this
survey is completely voluntary; there are no right or wrong answers; and you may contact us with any questions that you
have before, during, or after you complete the survey.
Privacy: Your answers to the survey questions will be kept private except as otherwise required by law. Your name will not
be linked with the information on your survey. The information that we report to OASH will not contain your name. Your name
will not be used in any reports about this evaluation.
Procedures: All coalition members are being asked to complete this survey. Therefore, your participation is very important.
The survey questions will ask you about your feedback and recommendations for improving the Guide.
Risks: There are few, if any, risks to you by completing this survey. You may stop the survey at any time. You will not be
penalized for stopping. If you stop the survey, at your request, we will destroy your survey.
Contact information: If you have any concerns about completing this survey or have any questions about the study, please
contact Gingi Pica, Project Manager, at 212-941-5555 or gingi.pica@icfi.com.
Thank you in advance for your willingness to participate.
Your responses are very important to us.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to
average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S.
Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports
Clearance Officer

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Second Decade Community Planning Guide - Coalition Assessment Survey

Please select the coalition that you participated in to pilot the Office of the Assistant Secretary for
Health's (OASH) Second Decade Community Planning Guide.
Be Healthy QC, Davenport Parks and Recreation
Cincinnati Children's Hospital
Commonwealth Healthcare Corporation
Family and Children First Council, Allen County Public Health Department
Healthy Heart Coalition

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Second Decade Community Planning Guide - Coalition Assessment Survey

INTRODUCTION
We recognize that you may participate in a number of coalitions, task forces and activities in your community. For the
purposes of this survey, we are asking you to think about your involvement in the coalition and activities related to the
Second Decade Project Community Planning Guide [Q1] coalition. We refer to the Second Decade Community Planning
Guide as ‘the Guide’ throughout the survey.

Please indicate your level of agreement with the following statements regarding the
overall format of the Guide:
1. Guide Format
Strongly
Disagree

No opinion
Disagree

or uncertain

Strongly
Agree

Agree

The main message of the Guide was easy to identify
The Guide is an appropriate length
The Guide has an appealing design
The overall format of the Guide is easy to follow
The chapters in the Guide are well organized and have
coherent flow
The Guide has an appropriate level of detail throughout
The Guide provided useful information on specific issues
related to youth 10-19
The Guide provided useful information about the availability
of resources related to youth 10-19
Our coalition used the resources provided in the Guide
The resources provided in the Guide are easy to identify

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