Form Organizer Survey Organizer Survey Organizer Survey

Attachment C: Organizer Survey

OMB No. 0930-0288

Expiration Date: xx/xx/20xx

Burden Statement: This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) for the purpose of program monitoring of Communities Talk to Prevent Alcohol and Other Drug Misuse initiative. This voluntary information collected will be used at an aggregate level to assess the Communities Talk stipend recipients’ experiences with the events and alcohol and other drug misuse prevention activities deployed by their organizations or institutions. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent of the law. 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 Office of Management and Budget (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 15 minutes per encounter, 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 Ln, Room 15 E57B, Rockville, MD 20857.

Communities Talk to Prevent Alcohol and Other Drug Misuse Survey

INFORMED CONSENT STATEMENT

On behalf of the Substance Abuse and Mental Health Services Administration (SAMHSA), one of its contractors called ICF Next invites prevention specialists working individually or as part of a coalition to fill out this survey. A coalition refers to any group of individuals or organizations working together. This survey asks about your possible experiences with Communities Talk to Prevent Alcohol and Other Drug Misuse and how your community might be carrying out evidence-based strategies to prevent alcohol and other drug misuse. Evidence-based strategies have been evaluated and found to have positive effects on the intended audience. The survey should take approximately 15 minutes. Your participation is completely voluntary. You can stop at any time. Refusal to participate will not affect your employment, funding for your work, or result in any other penalty or loss of benefit. The evaluation team will keep your survey answers in a password-protected computer folder. It will be accessed only by the evaluation team. The evaluation team will summarize everyone’s answers in a report. The evaluation team will keep your name and contact information separate from your answers. We collect your name and contact information only to monitor who has already completed the survey, as to not request more than one response per organization. The report will not identify you and the person documenting survey completions will not analyze the data. Your thoughts are very important. They will help SAMHSA improve how it supports community-based prevention efforts. If you have any questions, please contact Dr. Genevieve Martinez-Garcia or Sarah Caban, Study Administrators, at info@stopalcoholabuse.net.

By continuing, you are consenting to participate in this survey on behalf of your coalition or you.

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NOTE: As you complete each page of the survey and click the right arrow, data entered will be automatically saved. This feature allows you to return to the survey to make changes or finish completing it. You will be allowed to return to the survey until the last question is answered.

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.

Importance of Alcohol and Other Drug Misuse

Q1 In your opinion, how important of an issue is alcohol and other drug misuse, and its consequences, to the residents of your community?

• Very important

• Important

• Moderately important

• Slightly important

• Not important

• I don’t know

Communities Talk

Q2 What is the total number of Communities Talk activities hosted in your community during this calendar year? These events may have been primarily hosted by your organization or a different one.

Note: If an exact number cannot be provided, please provide your best estimate. Please provide as accurate of a number as possible.

# activities primarily hosted by your organization: __________

# activities primarily hosted by a different organization: __________

Q3 What was the total number of attendees at your most recent Communities Talk activity? (Estimates are okay.)

# of physical (in-person) attendees: _______________

# of virtual (not in-person) attendees: _______________

Q4. What substances/topics, if any, will your Communities Talk activity cover? Choose all that apply.*

• E-cigarettes/vaping

• Prescription opioids

• Fentanyl

• Naloxone

• Marijuana

• Heroin

• Cocaine

• Methamphetamines

• Mental health

• Suicide

• Alcohol

• Other: [FILL IN]

Evidence-Based Strategies

Q5 Evidence-based strategies have been evaluated and found to have positive effects on the intended audience. Certain advance preparation may or may not help professionals build their capacity to carry out any number of evidence-based strategies to prevent alcohol and other drug misuse in their community (e.g., advisory board or committees on alcohol and/or other drug misuse prevention, youth-led coalition on alcohol and/or other drug misuse prevention). Some of the preparation may be tied to Communities Talk, while some of the preparation may not be tied to Communities Talk. This question asks about your organization’s preparation for evidence-based strategies, other than hosting a Communities Talk activity. How much have you completed of the following steps?

	Not Started	Started and Partly Completed	Started and Fully Completed
Got resources (e.g., time, funding, equipment)
Read materials on how to conduct evidence-based strategies (e.g., website, handbook, toolkit, checklist)
Made plans to use the materials on how to conduct evidence-based strategies
Got training
Talked to one or more of my managers
Talked to one or more of my peers
Got one-on-one advice

Q6 Have you used any material(s) from the Communities Talk website (www.stopalcoholabuse.gov/communitiestalk)?

• Yes

• No

Q6A <If Q6=Yes> What material(s) from the Communities Talk website (www.stopalcoholabuse.gov/communitiestalk) have you used?

• Quick Start Planning Guide

• Tips & Tools for Hosting a Virtual Activity (e.g., virtual activity starters and ideas)

• Using Social Media guides

• Social Media Images/Graphics

• Customizable Resources for Communities Talk Promotion and Implementation (e.g., PowerPoint template, flyer, logo, web badge)

• Prevention Event Planner web app

• Other (please specify) _______________

Q7 Please rate your agreement with the following statement: I know how to use evidence-based approaches to carry out future alcohol and other drug misuse prevention activities.

• Strongly agree

• Agree

• Disagree

• Strongly disagree

Q8 Prevention professionals take several steps as part of their evidence-based work. How confident are you that you can carry out the following tasks?

**If a task is outside your organization’s authority, please select “not applicable”.

	Not confident	Somewhat confident	Very confident	Not applicable
Assess the needs and resources of the community
Define priority populations
Create goals and objectives
Choose evidence-based strategies
Tailor the evidence-based strategies to the community
Assess organizational capacities to implement the evidence-based strategies
Plan to implement the evidence-based strategies
Find materials for priority populations
Acquire/get materials for priority populations
Manage coalition members
Monitor implementation of the evidence-based strategies
Evaluate the evidence-based strategies
Continually improve the evidence-based strategies
Sustain the evidence-based strategies
Collaborate with others to implement resources or programming
Work with my local legislators or policymakers to create laws and/ or policies

Q9 There are many ways to prevent alcohol and other drug misuse in a community. Different communities need different evidence-based strategies. SAMHSA wants to learn what works best for your community. Currently, which of the following activities are you or your organization collaborating on with others to prevent alcohol and other drug misuse in your community? (Mark all that apply.)

• Hold meetings or discussion groups on alcohol and/or other drug misuse prevention

• Create alcohol and/or other drug misuse prevention action groups (e.g., committees, task forces, and advisory boards)

• Start a youth-led coalition on alcohol and/or other drug misuse prevention

• Develop strategic plans to reduce and prevent alcohol and/or other drug misuse

• Build coalitions with other agencies or programs to reduce and prevent alcohol and/or other drug misuse Enforce compliance checks to reduce youth access to alcohol and/or other drugs.

• Encourage responsible beverage server training

• Reduce or limit alcohol and/or other drugs outlet density

• Increase taxes on alcohol sales

• Increase sobriety and traffic safety checkpoints

• Limit sales of alcohol at public events where youth are present

• Prevent sales of other drugs at public events where youth are present

• Reduce the number of hours for possible happy hours

• Implement social host ordinances

• Draft policy changes for my community that focus on alcohol and/or other drug misuse prevention

• Work with my local legislators or policymakers to educate about the importance of changes to, or recommend enforcement of, existing laws and policies

• Other (please specify): _______________

Q10 For the activities mentioned in Q9, what types of organizations do you typically collaborate with (check all that apply)?

• Faith-based based organizations

• Law enforcement

• Youth-led organizations

• Secondary schools

• Elementary schools

• Colleges or universities

• Other community-based organizations

• Local chapters of national organizations

• Charitable organizations

• Local businesses

• State and local government agencies (e.g., public health departments)

• Other

• None

Q11 How many partners does your organization coordinate with for activities on a monthly basis? This can be an estimated number.

# of collaboration partners engaged per month _____

Q12 A community’s needs and its resources may change over time. In the future, how likely is it that you or your organization will plan or collaborate with others on the following activities to prevent alcohol and other drug misuse in your community?

	Very Likely	Somewhat Likely	Not Likely
Hold follow-up meetings or discussion groups on alcohol and/or other drug misuse prevention
Create alcohol and/or other drug misuse prevention action groups (e.g., committees, task forces, and advisory boards)
Start a youth-led coalition on alcohol and/or other drug misuse prevention
Develop strategic plans to reduce and alcohol and/or other drug misuse
Build coalitions with other agencies or programs to reduce and prevent alcohol and/or other drug misuse
Enforce compliance checks to reduce youth access to alcohol and/or other drugs
Encourage responsible beverage server training
Reduce or limit alcohol and/or other drugs outlet density
Increase taxes on alcohol sales
Increase sobriety and traffic safety checkpoints
Limit sales of alcohol at public events where youth are present
Prevent sales of other drugs at public events where youth are present
Reduce the number of hours for possible happy hours
Implement social host ordinances
Draft policy changes for my community that focus on alcohol and/or other drug misuse prevention
Work with local legislators or policymakers to educate about the importance of changes to, or recommend enforcement of, existing laws and policies

Usefulness of Communities Talk

Q13 Think about all of the Communities Talk activities that might have taken place in your community. How much do you agree with the following statements?

	Strongly Agree	Agree	Disagree	Strongly Disagree
Communities Talk has increased my knowledge of how my community can prevent alcohol and other drug misuse in my community.
Communities Talk has increased my community’s capacity to prevent alcohol and other drug misuse
Communities Talk is advancing the prevention of alcohol and other drug misuse in my community.
Communities Talk meets significant alcohol and other drug use prevention needs within our community.
Communities Talk was easy to implement in my community.

Q14 Do you have a report or something else (e.g., tables) that includes alcohol and other drug misuse data at the community level (e.g., incidences of use; activities or actions employed to prevent and combat alcohol and other drug misuse)?

• Yes

• No

Q14A <If Q13=Yes> Would you be willing to share the report with SAMHSA?

• Yes

• No

Q14B <If Q13A=Yes> Please send the report to the following address:

info@stopalcoholabuse.net

[or]

ICF

Attn.: Communities Talk—Genevieve Martinez-Garcia

530 Gaither Rd, Suite 500, Rockville, MD 20857

Demographics

Q15 How would you characterize the location where your Communities Talk activity was held?

• Rural

• Urban

• Suburban

• Reservation

• Other (please specify): _______________

• N/A

Q16 Which of the following best describes your organization?

• Community-based organization

• Institution of higher education

• Other (please specify) __________

Q17 Which of the following best describes the primary audience(s) served by your organization? (Mark all that apply.)

• Youth

• Parents

• Teachers or other education staff

• Prevention specialists and volunteers

• Law enforcement officials

• Legislators or policymakers

• Doctors, nurses, or other health care professionals

• Youth leaders (e.g., coaches, parks and recreation personnel, and scouting leaders)

• Healthcare providers

• Clergy

• The media

• American Indian or Alaska Native community members

• Asian community members

• Black or African American community members

• Hispanic community members

• Native Hawaiian or Other Pacific Islander community members

• Lesbian, gay, bisexual, or transgender (LGBTQ) community members

• Other (please specify) __________
  
  

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Thank you again for sharing this important information about your experience with Communities Talk and alcohol and other drug misuse prevention activities in your community! Visit https://www.stopalcoholabuse.gov/communitiestalk/ for the most current updates.

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