ATTACHMENT G
OMB No. __0920-XXX__
Exp. Date _xx/xx/20xx_
COALITION MEMBER SURVEY
Public
Reporting burden of this collection
of information is estimated at 30 minutes per response, including
the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. An agency many 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. Send comments regarding this burden estimate or any
other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance
Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; Attn:
PRA (0920-XXXX).
About You
Name: __________
Are you: male female
Age: (give ranges used in census)
Are you of Hispanic or Latino origin or descent?
Yes
No
5. Which of the following best describes you? (Check one or more)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Who is your employer? ____________________
What is your job title? ____________________
What is your role within the coalition?
Leader
Member
Other (Please explain: ________________)
What is your background with youth violence? (Please check all that apply)
Formal Education
Work Experience
Survivor/Family History
Advocate
Other: (Please explain:___________________)
10. Do you represent an individual or an organization in the coalition?
Individual
Organization (Please provide organization’s name: ________________)
11. How would you rate your computer experience?
Novice – I am new to computers and/or I only use one for a specific purpose.
Low – I am somewhat new to computers and/or I am relatively comfortable with one or two software applications or programs (e.g. Microsoft Word, Excel, etc.)
Intermediate – I am comfortable with computers and/or I have learned and use between three and ten different software applications and programs.
Expert – I know my way around computers and/or I am comfortable troubleshooting most of the problems that arise with computers and I have used many different software applications and have some programming skills.
12. Have you visited the safeyouth.org website? Y N (If no, skip to Q26)
13. Which of the following online training courses have you completed?
Lesson 1:
Lesson 2:
Lesson 3:
14. If you did not complete all three training modules, why not?
Did not have enough time
Did not think the training would be useful
Did not like the training I did complete
Already familiar with the material in the training
Training I completed did not help me with my coalition activities
Other (Please explain:________________________)
Safeyouth.org website
Please rate the following statements about the Safeyouth.org website on a scale of 1 to 5 with 1= Strongly Disagree to 5= Strongly Agree. If a question does not pertain to you, please write NA for not applicable.
_____15. I like the look and feel of the website.
_____16. I found the information I was looking for on the website easily.
_____17. I found interesting and useful information on the website that I wasn’t even looking for.
_____18. The website has good depth of information on youth violence prevention.
_____19. I would recommend this website to others interested in youth violence prevention.
_____20. The information provided through the online training was useful for my work within the coalition.
_____21. I found the online trainings to be engaging.
_____22. Our coalition utilized the tools available on website to help organize the coalition.
_____23. Our coalition utilized the tools on the website to conduct strategic planning activities.
_____24. Our coalition utilized the tools on the website to help support actions we are taking in our community to prevent youth violence.
_____25. Organizing and planning activities that were conducted offline, were later documented on the online workspace.
Perception of the coalition
Please rate your agreement to the statements below on a scale of 1 to 7 with 1=strongly disagree and 7=strongly agree.
_____26. Leadership has a clear vision for the coalition.
_____27. The coalition has agreed on how it will govern itself, make decisions and clarify the roles of members.
_____28. The coalition has a core group that organizes its efforts.
_____29. People in the community know what the mission and objectives of the coalition are.
_____30. The leadership has relationships with diverse groups (e.g. local businesses, religious, institutions, colleges and universities) that can help the coalition.
_____31. The coalition leadership is respected in your community.
_____32. The coalition leadership is able to mobilize resources to aid the coalition.
_____33. People involved with the coalition have or can obtain information the coalition needs to succeed.
_____34. The leadership has relationships with public officials who can help the coalition.
_____35. There is a feeling of unity and cohesion in this coalition.
_____36. It is difficult to develop a sense of trust with other coalition members.
_____37. There has been in-fighting among coalition members.
_____38. It has been difficult to get the “right” people to join the coalition – that is, people with the skills, talents or political connections needed.
_____39. It has been difficult to get coalition members to make a strong enough commitment or work hard enough on the coalition.
_____40. It has been difficult to acquire needed resources (for example, money or space).
41. What were (or do you anticipate to be) the top three challenges during the first six months of the coalition’s activities? (Please check up to three boxes)
Recruiting diverse members
Obtaining effective leaders
Obtaining member participation
Maintaining momentum
Adapting to changes in member participation
Orienting and training members
Resolving conflicts and problems
Making decisions
Planning and goal setting
Implementing strategies
Evaluating progress
Fostering collaboration
Knowing what to do next
Conducting a community needs assessment
Obtaining funding
Participating in a planning process rather than being more action oriented
42. For each of the following training/technical assistance topics, please mark whether the coalition members received any training in 2009 and will require training in 2010.
Technical Assistance Needs |
Received |
Needed |
Evidence based planning |
|
|
Conducting needs assessments |
|
|
Partnering with business |
|
|
Community organizing |
|
|
Strategic planning and goal setting |
|
|
Program sustainability |
|
|
Selecting evidence based programs and curricula |
|
|
Maintaining or enhancing coalition stability |
|
|
Group processes and team building |
|
|
Other |
|
|
Community Improvement
Please rate the extent to which the following areas have changed since the coalition was formed on a scale of 1 to 7 with 1=a lot worse and 7=a great deal better.
_____43. Community-wide awareness of youth prevention programs.
_____44. Community prevention planning is systematic and comprehensive.
_____45. People are equipped to work collectively on community issues.
_____46. People feel that together we can make a difference.
_____47. Well-being of people in our community.
_____48. Local policies towards adolescent behavior problems and risk factors (e.g., schools, police, courts, county agencies, etc.).
Thank you for your time. We appreciate your input!
File Type | application/msword |
File Title | In which of the following ways do prevention subcommittee members share and distribute information with one another about planni |
Author | Cynthia Klein |
Last Modified By | mle4 |
File Modified | 2009-03-19 |
File Created | 2009-02-19 |