Form Survey

Attachment 2

STOP ACT SURVEY (WITH RECOMMENDED REVISIONS)

OMB Statement

OMB No. 0930-0316

Expiration Date: 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 0930­0316. Public reporting burden for this collection of information is estimated to average 17.7 hours 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, 5600 Fishers Lane, Room 15E57B,

Rockville, Maryland, 20857.

.

General Instructions

This survey represents one of several data collection efforts initiated by the Secretary of HHS initiated pursuant to a Congressional directive found in the Sober Truth on Preventing Underage Drinking (STOP) Act, (Pub. L. No. 109­422, § 2, 120 Stat. 2890 [2006]). The Act requires the Secretary to file an annual report to Congress on the states’ progress in preventing and reducing underage drinking. As stated in the STOP Act:

“The Secretary shall, with input and collaboration from other appropriate Federal agencies, States, Indian tribes, territories, and public health, consumer, and alcohol beverage industry groups, annually issue a report on each State's performance in enacting, enforcing, and creating laws, regulations, and programs to prevent or reduce underage drinking.”

The Act provides a list of specific underage drinking laws and policies, details regarding their enforcement, and other programs that the Secretary should include in the annual report. Federal data sources provide some of the data requested. The questionnaire, which asks for the data requested by Congress, provides states the opportunity to participate in the process and to insure accurate and complete reporting.

PLEASE NOTE:

1) SAMHSA will report only the data you provide. Any question your state does not answer will be reported as “No Data” or "Not Collected".

2) To be included in the STOP Act report, this survey must be received by SAMHSA no later than XX/XX/XXXX.

3) The survey is composed of 90 numbered questions. Each section ends with a space where additional remarks may be added for clarification, as needed.

4) At the end of each part of the survey, you will be asked to name a person whom we may contact if clarification is needed. This person will NOT BE IDENTIFIED in any reports that result from this survey.

Please submit any technical assistance requests via email to stopactsurvey@cdmgroup.com or by telephone to 301-654-6740.

Thank you in advance for your cooperation.

SURVEY, PART 1 -- ENFORCEMENT

Please enter your state below:

_________________________________

Part 1, Section A: State Agency

1.A.1) Please identify the state agency/department that has PRIMARY RESPONSIBILITY for ENFORCING laws designed to prevent underage drinking (e.g., sales and/or furnishing of alcohol to underage persons, social host laws, underage persons in possession, etc.).

_______________________________________________________________________

Part 1, Section A: Number of Retail Licensees

1.A,2) Based on readily available data, please provide an estimate of the number of retail licensees in your state (excluding special licenses such as temporary, seasonal, and common carrier licenses).

________

Part 1, Section A: Enforcement Strategies

1.A.3 Do state or local law enforcement agencies engage on a regular basis in any of the following (see definitions):

	Cops in Shops	Shoulder Tap Operations	Party Patrol Operations or Programs	Underage Alcohol­Related Fatality Investigations
State
Local

Definitions for Question 1.A.3:

COPS IN SHOPS: A well-publicized enforcement effort in which undercover law enforcement officers are placed in retail alcohol outlets.

SHOULDER TAP: Trained young people (decoys) approach individuals outside of retail alcohol outlets and ask the individuals to make an alcohol purchase.

PARTY PATROL OPERATIONS OR PROGRAMS: Operations that identify underage drinking parties, make arrests and issue citations, and safely disperse participants.

UNDERAGE ALCOHOL-RELATED FATALITY INVESTIGATIONS: Investigations to determine the source of alcohol ingested by fatally injured minors.

Part 1, Section A: Underage Persons in Possession

1.A.4) Does your state collect data/maintain records on the number of underage persons found in possession?

__ Yes

__ No

__ Don't know

If ‘No” or “Don’t know/no answer,” please go to Question 1.B.1.

If yes, based on readily available data, please provide estimates of how many underage persons the state found in possession (or having consumed or purchased per your state statutes) of alcohol during the most recent year for which complete data are available.

Number of Minors ____

Period for which data in 1.A.4 are reported: In 12 months ending __/__/____ (MM/DD/YYYY)

Do the data provided above include arrests/citations issued by local law enforcement agencies?

__ Yes

__ No

__ Don't know

Part 1, Section B

Part 1, Section B1: Compliance Checks, State Level

Definition for Questions 1.B.1-1.B.2:

COMPLIANCE CHECKS/DECOY OPERATIONS: Sending trained underage (or apparently underage) volunteers into retail outlets to attempt to purchase alcohol.

Note: The questions under 1.B.1 deal with UNDERAGE COMPLIANCE CHECKS/DECOY OPERATIONS (see definition) at the STATE level.

1.B.1) Does your state alcohol law enforcement agency conduct underage compliance checks/decoy operations to determine whether alcohol retailers are complying with laws prohibiting sales to underage persons? Do you collect data on these activities?

__ Yes, WE CONDUCT THESE ACTIVITIES, and WE COLLECT DATA on them.

__ Yes, WE CONDUCT THESE ACTIVITIES, but we DO NOT collect data on them.

__ No, we neither conduct these activities nor collect data on them.

__ Don’t know/no answer

If ‘No” or “Don’t know/no answer,” please go to Question 1.B.2.

1.B.1.a) Based on readily available data, please provide an estimate of the number of licensees in your state upon which underage compliance checks/decoy operations were conducted by your primary state alcohol law enforcement agency. Please report on the most recent year for which you have complete data. (If you do not collect these particular data, please leave blank.)

________

1.B.1.b) Based on readily available data, please provide estimates of the number of licensees that failed these state compliance checks/decoy operations by selling or serving an alcoholic beverage to an underage individual. Please report on the most recent year for which you have complete data. (If you do not collect these particular data, please leave blank.)

Total Number Who Failed ____

1.B.1.c) Are the compliance checks/decoy operations conducted at both on-sale and off-sale retail establishments?

_____On-sale establishments only

_____Off-sale establishments only

_____Both on- and off-sale establishments

1.B.1.d) Period for which data in 1.B.1.a through 1.B.1.b are reported: In 12 months ending __/__/____ (MM/DD/YYYY)

1.B.1.e) Does your state alcohol law enforcement agency conduct random compliance checks/decoy operations?

Definition for Question 1.B.1.e:

RANDOM COMPLIANCE CHECKS: Compliance checks that are conducted by random selection and NOT as a convenience sample or in response to complaints.

___ Yes

___ No

___ Don’t know

If ‘No” or “Don’t know/no answer,” please go to Question 1.B.2.

If yes, based on readily available data, please provide:

______Number of licensees in your state upon which random compliance checks/decoy operations were conducted. Please report on the most recent year for which you have complete data.

______Number of licensees that failed the random compliance checks/decoy operations.

Part 1, Section B2: Compliance Checks, Local Level

Note: The questions under 1.B.2 deal with UNDERAGE COMPLIANCE CHECKS/DECOY OPERATIONS at the LOCAL Level.

1.B.2) ­ Do local law enforcement agencies conduct underage compliance checks/decoy operations to determine whether alcohol retailers are complying with these laws? Do you collect data on these activities?

__ Yes, local law enforcement agencies CONDUCT THESE ACTIVITIES, and WE COLLECT DATA on them.

__ Yes, local law enforcement agencies CONDUCT THESE ACTIVITIES, but we DO NOT COLLECT data on them.

__ No, local law enforcement agencies do not conduct these activities and we do not collect data on them.

__ Don’t know/no answer

If ‘No” or “Don’t know/no answer,” please go to Section C.

1.B.2.a) Based on readily available data, please provide an estimate of the number of licensees in your state upon which underage compliance checks/decoy operations were conducted by local law enforcement agencies. Please report on the most recent year for which you have complete data. (If you do not collect these particular data, please leave blank.)

__________

1.B.2.b) Based on readily available data, what was the TOTAL number of licensees who failed the local compliance check/decoy operations by selling or serving an alcoholic beverage to an underage individual? Please report on the most recent year for which complete data are available. (If you do not collect these particular data, please leave blank)

__________

1.B.2.c) Period for which data in 1.B.2.a and 1.B.2.b are reported: In 12 months ending __/__/____ (MM/DD/YYYY)

Part 1, Section C:

This section includes questions on sanctions imposed for retail furnishing of alcohol to underage persons.

Please provide data based on FINAL DISPOSITIONS, not charges.

Part 1, Section C: Sanctions, Fines

1.C.1) Does your state collect data/maintain records on the NUMBER and/or TOTAL AMOUNT of FINES imposed on retail establishments for furnishing to underage persons?

____ Yes

____ No

____ Don't know

If “No” or “Don’t know”, please go to Question 1.C.3.

Based on readily available data, please provide estimates of the following over the last 12 month period for which complete data are available. Do not include fines imposed by local agencies.

Enter a zero (0) if no fines were imposed in the 12 month period.

______ Number of Fines (If you do not collect these particular data, please leave blank)

_______ Total Amount of Fines In Dollars Across all Licensees (If you do not collect these particular data, please leave blank)

Smallest fine imposed on a retail establishment for furnishing alcohol to minors _________

Largest fine imposed on a retail establishment for furnishing alcohol to minors__________

1.C.2) Period for which data in 1.C.1 are reported: In 12 months ending __/__/____ (MM/DD/YYYY)

Part 1, Section C: Sanctions, License Suspensions

1.C.3) Does your state collect data on LICENSE SUSPENSIONS imposed on retail establishments specifically for furnishing to underage persons?

___ Yes

___ No

___ Don't know

If “No” or “Don’t know,” please go to 1.C.5.

Based on readily available data, please provide estimates of the following over the last 12 month period for which complete data are available. Do not include suspensions imposed by local agencies.

Enter a zero (0) if no suspensions were imposed in the 12 month period.

____ Number of suspensions (If you do not collect these particular data, please leave blank.)

____ Total days of suspensions across all licensees (If you do not collect these particular data, please leave blank.)

Shortest period of suspension imposed on a retail establishment for furnishing alcohol to minors (in days) _________

Longest period of suspension imposed on a retail establishment for furnishing alcohol to minors (in days) __________

1.C.4) Period for which data in C.3 are reported: In 12 months ending __/__/____ (MM/DD/YYYY)

Part 1, Section C: Sanctions, Revocations

1.C.5) Does your state collect data on LICENSE REVOCATIONS imposed on retail establishments specifically for furnishing to underage persons?

___ Yes

___ No

___ Revocation is not an enforcement option in our state

___ Don't know

If “No, ” “Revocation is not an enforcement option in our state,” or “Don’t know,” please go to Section D.

If yes, based on readily available data, please provide estimates of the following over the last 12 month period for which complete data are available. Do not include revocations imposed by local agencies.

Enter a zero (0) if no revocations were imposed in the 12 month period.

___ Number of revocations

1.C.6) Period for which data are reported in 1.C.5: In 12 months ending __/__/____ (MM/DD/YYYY)

Part 1, Section D: Internet Sales and Direct Shipping

This section deals with laws pertaining to INTERNET SALES AND DIRECT SHIPPING of alcohol.

Definition for Questions 1.D.1 and 1.D.2:

DIRECT SALES/SHIPMENT LAWS: Laws which permit, regulate or prohibit direct-to-consumer sales of wine, beer or spirits via the internet or via delivery by common carrier. Direct sales laws do not address home deliveries by retailers to consumers without the use of common carriers.

1.D.1) Does your state have a program to investigate and enforce direct sales/shipment laws?

___ Yes

___ No

___ Don't know

If “No” or “Don’t know,” please go to Section E.

If yes, please identify the primary state agency responsible for enforcing laws addressing direct sales/shipments of alcohol to underage persons.

_______________________________________________________________________

1.D.2) Are these laws also enforced by local law enforcement agencies?

___ Yes

___ No

___ Don't know

Part 1, Section E: Enforcement Expenditures

This section requests estimates of the funds expended annually by your state specifically for the prevention of underage drinking under a variety of headings specified in the STOP Act. For this section, please DO NOT include federal, local or private funding sources.

For each activity or program listed on the following pages, please provide an estimate of the STATE FUNDS your state expended during the most recent year for which complete data are available. Please include only those activities or programs that your state funds, whether operated directly by the state or by another entity.

If you do not have access to relevant data, please check "These data are not available in my state."

(Please note: The STOP Act requires the Secretary of HHS to report PER CAPITA expenditures. The calculation of per capita rates will be made during the analysis of the survey using census data.)

1.E.1) UNDERAGE COMPLIANCE CHECKS IN RETAIL OUTLETS including provision of technology to detect and prevent the use of false identification by underage persons.

$_________ Estimate of state funds expended (dollars per 12-month period)

Period for which data are reported: 12 months ending __/__/____ (MM/DD/YYYY)

____ Can't answer this question; these data are not available in my state.

1.E.2) CHECKPOINTS AND SATURATION PATROLS that include the goal of reducing and deterring underage drinking. Please consider only those checkpoints and saturation patrols that your state FUNDS OR OPERATES DIRECTLY.

$_________ Estimate of state funds expended (dollars per 12-month period)

Period for which data are reported: 12 months ending __/__/____ (MM/DD/YYYY)

____ Can't answer this question; these data are not available in my state.

Part 1: Additional Clarification

Please use the space below to provide clarification of any of the information provided in Part 1 of the survey.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Part 1: Contact Information

Please provide the name and phone number or email of someone we can contact for additional clarification of the enforcement data reported in this section, if needed. This person will NOT BE IDENTIFIED in any reports that result from this survey.

Name_______________________________________________________________________

Phone number or email_______________________________________________________________________

THANK YOU FOR COMPLETING THIS PART OF THE SURVEY.

SURVEY, PART 2 – PROGRAMS, INTERAGENCY COLLABORATION, STATE EXPENDITURES FOR UNDERAGE DRINKING PREVENTION ACTIVITIES

PROGRAMS

Part 2, Section A: Programs

The first set of questions will ask about your state’s underage drinking prevention programs or campaigns.

Please list your state’s general prevention programs or campaigns that have underage drinking prevention as one objective. We are interested in all programs that your state funds or operates directly.

Please DO include state funded or operated programs or campaigns that serve as an "umbrella" for local initiatives. In such cases, please describe the umbrella program or campaign rather than the specifics of local activities.

Please DO include media campaigns that are intended to reduce and prevent underage drinking.

Please DO NOT include programs or policies that have as their primary objective the regulation of alcohol sales through state or local licensing of alcohol outlets.

Please briefly describe the program or campaign, including primary purpose, population served, and methods used.

2.A) Please enter your state below:

_________________________________

Program #1:

2.A.1) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to 9 additional programs on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.1.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.1.b) URL for more information about this program:

_______________________________________________________________________

2.A.1.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #2:

2.A.2) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to 8 additional programs on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.2.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.2.b) URL for more information about this program:

_______________________________________________________________________

2.A.2.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #3:

2.A.3) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to 7 additional programs on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.3.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.3.b) URL for more information about this program:

_______________________________________________________________________

2.A.3.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #4:

2.A.4) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to 6 additional programs on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.4.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.4.b) URL for more information about this program:

_______________________________________________________________________

2.A.4.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #5:

2.A.5) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to 5 additional programs on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.5.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.5.b) URL for more information about this program:

_______________________________________________________________________

2.A.5.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #6:

2.A.6) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to 4 additional programs on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.6.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.6.b) URL for more information about this program:

_______________________________________________________________________

2.A.6.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #7:

2.A.7) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to 3 additional programs on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.7.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.7.b) URL for more information about this program:

_______________________________________________________________________

2.A.7.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #8:

2.A.8) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to 2 additional programs on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.8.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.8.b) URL for more information about this program:

_______________________________________________________________________

2.A.8.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #9:

2.A.9) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to add up to1 additional program on the pages that follow.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.9.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.9.b) URL for more information about this program:

_______________________________________________________________________

2.A.9.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Do you wish to add another program?

___ Yes

___ No

If “No”, please go to question 2.A.11.

Program #10:

2.A.10) Please give the name of ONE underage drinking prevention program that your state OPERATES OR FUNDS. You may also provide a brief description of the program, the number of youth served by the program, the number of parents/caregivers served by the program, and a URL where further information on the program may be found.

You will be able to enter brief descriptions of any additional programs in Question 2.A.11.

Name of Underage Drinking Prevention Program:

_______________________________________________________________________

Program Description:

____________________________________________________________________________

____________________________________________________________________________

2.A.10.a.) Please provide an estimate of the number of the following different populations served in this program for the last year. If you do not collect these data, or if it is not possible to estimate the number served, please leave blank.

Number of youth (persons under age 21) served: ______

Number of parents (Individuals with primary responsibility for the wellbeing of a minor, including biological and adoptive parents, grandparents, foster parents, extended family, etc.) served: ______

Number of caregivers (people who provide services to youth including teachers, coaches, health and mental health care providers, human services and juvenile justice workers) served: ____

2.A.10.b) URL for more information about this program:

_______________________________________________________________________

2.A.10.c) Has this program been evaluated?

__ No

__ Yes, but there is no report available

__ Yes and there is a report available

Please provide URL or other source for report if available:______________________________

Additional Programs:

2.A.11) If you have additional underage drinking prevention programs that your state OPERATES or FUNDS, please identify them below with the program names, URLs if available, and a brief description of the programs:

____________________________________________________________________________

____________________________________________________________________________

Part 2, Section A: Additional Clarification

Please use the space below to provide clarification of any of the information provided in Part 2 of the survey.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Part 2, Section A: Contact Information

Please provide the name and phone number or email of someone we can contact for additional clarification of the program data reported in this section, if needed. This person will NOT BE IDENTIFIED in any reports that result from this survey.

Name_______________________________________________________________________

Phone number or email_______________________________________________________________________

THANK YOU FOR COMPLETING THIS PART OF THE SURVEY.

Part 2, Section B: Collaborations and Best Practices

2.B and 2.C): Please enter your state below:

_________________________________

COLLABORATIONS AND BEST PRACTICES

2.B.1) Does your state collaborate with federally recognized Tribal Governments in the prevention of underage drinking?

___ Yes

___ No

___ There are no federally recognized tribal governments in the state.

If “No” or “There are no federally recognized tribal governments…,” please go to question 2.B.2.

If yes, in the space provided below, please briefly describe these collaborations:

____________________________________________________________________________

____________________________________________________________________________

2.B.2) Does your state have programs to measure and/or reduce youth exposure to alcohol advertising and marketing?

___ Yes

___ No

If “No,” please go to question 2.B.3.

If yes, in the space provided below, please briefly describe these programs:

____________________________________________________________________________

____________________________________________________________________________

The following questions refer to social marketing efforts intended to reduce underage drinking and increase parent/child communications about alcohol consumption.

2.B.3.a) Does your state collaborate with/participate in any media campaigns to prevent underage drinking?

___ Yes

___ No

___ Don’t know/no answer

If “No” or “Don’t know/no answer,” please go to Question 2.B.4.

If “yes,” which of the following media campaigns does your state collaborate with or participate in? (Check all that apply.)

____ Federal campaigns [please specify]__________________________________________

____ Regional and local media campaigns [please specify]____________________________

____ Local school district efforts[please specify]_____________________________________

____ Other [please specify]_____________________________________________________

2.B.3.b. Does your state collaborate with/participate in SAMHSA’s national media campaign, “Talk. They Hear You.” (TTHY)?

___ Yes

___ No

___ Don’t know/no answer

If “No” or “Don’t know/no answer,” please go to Question 2.B.4.

If “yes,” how does your state participate in the TTHY media campaign? (Check all that apply.)

___ State officially endorses TTHY efforts

___ State commits state resources for TTHY

___ State forwards TTHY materials to local areas

___ Other [please specify]_____________________________________________________

If “yes,” how does your state procure funding for TTHY? (Check all that apply.)

____ Pro bono

____ Donated air time

____ Earned media

____ My state does not procure funding for TTHY

____ Other [please specify]_____________________________________________________

2.B.4) Does your state adhere to best practices standards for underage drinking programs?

___ Yes

___ No

If “No,” please go to Additional Clarification.

If yes, please indicate the type of agency/organization that established your best practices standards (please check all that apply):

___ Federal agency(ies) [please specify]__________________________________________

___ Agency(ies) within your state [please specify]___________________________________

___ Non-governmental agency(ies)[please specify]___________________________________

___ Other [please specify]______________________________________________________

2.B.5) In the space provided below, please describe your state’s best practice standards:

_______________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Part 2, Section B: Additional Clarification

Please use the space below to provide clarification of any of the information provided in Part 2 of the survey.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Part 2, Section B: Contact Information

Please provide the name and phone number or email of someone we can contact for additional clarification of the interagency collaboration data reported in this section, if needed. This person will NOT BE IDENTIFIED in any reports that result from this survey.

Name_______________________________________________________________________

Phone number or email_______________________________________________________________________

THANK YOU FOR COMPLETING THIS PART OF THE SURVEY.

Part 2, Section C: Interagency Collaboration

In this section, please provide information on interagency collaboration in your state to reduce underage drinking.

2.C.1) Is there a state-level interagency governmental body/committee that coordinates or addresses underage drinking prevention activities in your state?

__ Yes

__ No

__ Don’t know/No answer

If “No” or “Don’t know/no answer,” please go to question 2.C.2.

2.C.1.a) If yes, please provide a committee contact (the chair of the committee or other primary person) in the space below:

Name:____________________________________________________________________

Email:_____________________________________________________________________

Address:___________________________________________________________________

Phone:____________________________________________________________________

2.C.1.b) Please list the agencies/organizations represented on the committee. If there are more than ten agencies/organizations, please add additional lines.

1.__________________________________________________________________________

2.__________________________________________________________________________

3.__________________________________________________________________________

4.__________________________________________________________________________

5.__________________________________________________________________________

6.__________________________________________________________________________

7.__________________________________________________________________________

8.__________________________________________________________________________

9.__________________________________________________________________________

10._________________________________________________________________________

Additional Agencies/Organizations:

.__________________________________________________________________________

.__________________________________________________________________________

.__________________________________________________________________________

.__________________________________________________________________________

.__________________________________________________________________________

.__________________________________________________________________________

2.C.1.c) Is there a website or other public source that describes the committee’s activities?

__ Yes

__ No

If “No,” please go to question 2.C.2.

Please provide a website address or other means to access this information.

2.C.2) Has your state prepared a PLAN for preventing underage drinking in the last three years?

__ Yes

__ No

__ Not sure

If “No” or “Not sure,” please go to question 2.C.3.

2.C.2.a) If yes, what agency, committee or other body prepared the plan?

____________________________________________________________________________

2.C.2.b) If available, please provide a website address or other means to access the plan.

____________________________________________________________________________

2.C.3) Has your state prepared a REPORT on underage drinking in the last three years?

____________________________________________________________________________

__ Yes

__ No

__ Not sure

If “No” or “Not sure,” please go to Additional Clarification.

2.C.3.a) If yes, what agency, committee or other body prepared the report?

_________________________________________________________________________

2.C.3.b) If available, please provide the website address or other means to access the report.

____________________________________________________________________________

Part 2, Section C: Additional Clarification

Please use the space below to provide clarification of any of the information provided in this section of the survey.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Part 2, Section C: Contact Information

Please provide the name and phone number or email of someone we can contact for additional clarification of the interagency collaboration data reported in this section, if needed. This person will NOT BE IDENTIFIED in any reports that result from this survey.

Name_______________________________________________________________________

Phone number or email_______________________________________________________________________

THANK YOU FOR COMPLETING THIS PART OF THE SURVEY.

STATE EXPENDITURES

Part 2, Section D: State Expenditures for Underage Drinking Prevention Activities

This part requests estimates of the funds expended annually by your state specifically for the prevention of underage drinking under a variety of headings specified in the STOP Act.

For each activity or program listed on the following pages, please provide an estimate of the STATE FUNDS your state expended during the most recent year for which complete data are available. Please DO NOT include federal, local or private funding sources.

If your state does not have access to relevant data, please check “These data are not available in my state.” If it is not possible to distinguish funds expended specifically for the prevention of underage drinking from a general fund targeted to an activity or program listed below, please check “These data are not available in my state.”

Please Note: The STOP Act requires the Secretary of HHS to report per capita expenditures. The calculation of per capita rates will be made during the analysis of the survey using census data.

2.D) Please enter your state below:

_________________________________

Part 2, Section D: Community-Based Expenditures

2.D.1) COMMUNITY-BASED programs to prevent underage drinking.

$______ Estimate of state funds expended (dollars per 12-month period)

Period for which data are reported: 12 months ending __/__/____ (MM/DD/YYYY)

____ Can't answer this question; these data are not available in my state.

Part 2, Section D: K-12 School-Based Expenditures

2.D.2) K-12 SCHOOL-BASED programs to prevent underage drinking.

$______ Estimate of state funds expended (dollars per 12-month period)

Period for which data are reported: 12 months ending __/__/____ (MM/DD/YYYY)

____ Can't answer this question; these data are not available in my state.

Part 2, Section D: Institutes of Higher Education Expenditures

2.D.3) Programs to prevent underage drinking targeted at INSTITUTIONS OF HIGHER EDUCATION.

$______ Estimate of state funds expended (dollars per 12-month period)

Period for which data are reported: 12 months ending __/__/____ (MM/DD/YYYY)

____ Can't answer this question; these data are not available in my state.

Part 2, Section D: Juvenile Justice System Expenditures

2.D.4) Underage drinking prevention programs that target youth within the JUVENILE JUSTICE SYSTEM.

$______ Estimate of state funds expended (dollars per 12-month period

Period for which data are reported: 12 months ending __/__/____ (MM/DD/YYYY)

____ Can't answer this question; these data are not available in my state.

Part 2, Section D: Child Welfare System Expenditures

2.D.5) Underage drinking prevention programs that target youth within the CHILD WELFARE SYSTEM.

$______ Estimate of state funds expended (dollars per 12-month period)

Period for which data are reported: 12 months ending __/__/____ (MM/DD/YYYY)

____ Can't answer this question; these data are not available in my state.

Part 2, Section D: Other Expenditures

2.D.6) Please provide an estimate of the state funds your state expended during the most recent year for which complete data are available for any underage drinking programs or strategies other than those listed above.

Programs or Strategies (please list):

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

$______ Estimate of state funds expended (dollars per 12-month period)

Period for which data are reported: 12 months ending __/__/____ (MM/DD/YYYY)

____ Can't answer this question; these data are not available in my state.

Part 2, Section D: Sources of Funding

2.D.7) Sources of Funding: Are funds dedicated to underage drinking prevention derived from any of the following revenue streams in your state?

	YES	NO
Taxes
Fines
Fees
Other (please specify)

2.D.8) If you answered yes to any of the above, please briefly describe these funding streams and how they are used.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Part 2, Section D: Additional Clarification

Please use the space below to provide clarification of any of the information provided in this section of the survey.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Part 2, Section D: Contact Information

Please provide the name and phone number or email of someone we can contact for additional clarification of the state expenditure data reported in this section, if needed. This person will NOT BE IDENTIFIED in any reports that result from this survey.

Name_______________________________________________________________________

Phone number or email_______________________________________________________________________

THANK YOU FOR COMPLETING THIS PART OF THE SURVEY.