Coalition Assessment Survey

Coalition Assessment Survey (CAS)

Form Approved

OMB No. 0990-

Exp. 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.

_________________________________________________________________________

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

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

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 Community Guide/insert local coalition name] coalition that is led by [insert name of lead agency]. We refer to the Second Decade Community Planning Guide as ‘the Guide’ throughout the interview.

Please indicate your level of agreement with the following statements regarding the overall format of the Guide:

Item	Response Option
	Strongly disagree	Disagree	No opinion or uncertain	Agree	Strongly agree
Guide Format
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

Please indicate your level of agreement with the following statements regarding the clarity of the directions provided in the Guide, its usability and effectiveness.

Item	Response Option
	Strongly disagree	Disagree	No opinion or uncertain	Agree	Strongly agree
Guide Directions, Usability, Effectiveness
The overall objectives of the Guide are clear
The Guide clearly explains the importance of the Second Decade
The Guide provides clear instructions on how to communicate with communities about the importance of the Second Decade
Our coalition used the Guide to develop strategies to communicate with our community about the importance of the second decade
The Guide was effective in helping our coalition communicate with our community about the importance of the second decade
The Guide provides clear instructions for identifying a champion in the community
Our coalition used the Guide to identify champions for young people and adolescents in our community
The Guide provides clear instructions for building a coalition
Our coalition used the Guide to help identify new coalition members
The Guide provides clear instructions for assessing a community’s strengths and gaps
Our coalition used the Guide to create a process to assess our community’s strengths and gaps
The Guide was effective in helping our coalition to identify assess our community’s strengths and gaps
The Guide provides clear instructions for developing a community action plan
Our coalition used the Guide to develop a community action plan
The Guide was effective in helping our coalition to develop a community action plan
The Guide provides clear instructions for applying multi-impact strategies in the community
Our coalition used the Guide to identify appropriate multi-impact strategies in our community
The Guide was effective in helping our coalition to apply multi-impact strategies in our community
The Guide clearly explains the importance of incorporating multi-impact strategies into a community action plan
The Guide provides clear guidance on specific issues that impact young people and adolescents
Our coalition used the Guide to address specific issues that impact young people and adolescents our community
Our coalition used the Guide to select more than one specific issue that impacts young people and adolescents to
The Guide was effective in helping our coalition to address specific issues that impact young people and adolescents our community
Please share additional feedback on the directions provided in the Guide overall
What additional multi-impact strategies would you recommend including in the Guide?
What additional issues that impact adolescents would you recommend including in the Guide?

Please respond to the following items about your coalition’s capacity and collaborations:

Item	Response Option
Please indicate your level of agreement with the following items:	Strongly disagree	Disagree	No opinion or uncertain	Agree	Strongly agree
Coalition Engagement
The Guide helped to facilitate communications between coalition members
The Guide helped to facilitate communications between Coalition and the broader community
The Guide helped the coalition to identify new coalition members who can help us address youth in the community.
The Guide helped to broaden our coalition membership to include non-traditional partners
The Guide has helped our coalition increase its capacity to improve adolescent health and well-being in our community

This set of questions are related to your Second Decade coalition’s activities and processes in developing your community plans. Please respond to the following items about your satisfaction with the coalition’s activities and processes:

Item	Response Option
How satisfied are you with…?	Very dissatisfied	Dissatisfied	Average	Satisfied	Very satisfied
Coalition Activities and Processes
Your coalition’s efforts to promote collaborative action in the community
The process used by your coalition to assess the community’s needs related to adolescents
Your coalition’s efforts to develop a community action plan to address the needs of adolescents
The multi-impact strategies your coalition applied in the community
The specific issues the coalition selected to address in the community
Your coalition’s efforts to implement the community action plan it developed
Item	Response Option
In the past year, please indicate how you have been personally involved in your community’s Second Decade coalition Select all that apply.	I Identified and ranked a set of high-priority action steps I specified immediate and short-term goals I helped to identify a champion I developed a mission statement I contributed to the Community Needs Assessment process I identified essential partners to join the coalition I assigned coalition members responsibilities and tasks I identified potential barriers and solutions for plan implementation I helped to develop funding strategies I monitored plan progress and evaluate plan outcomes I evaluated plan outcomes

The next set of questions asks about challenges you may have experienced using the Guide, suggestions for improvement, and frequency of use of the Guide.

Item	Response Option
Overall Guide Feedback
Which part of the Guide was most useful to your coalition?
Which part of the Guide was least useful to your coalition?
		Strongly disagree		Disagree		No opinion or uncertain		Agree	Strongly agree
Our coalition would not have been able to have an impact in our community without the Guide
The Guide was a central resource for the work our coalition did for youth and adolescents in the community
Our coalition used the Guide regularly
I am familiar with the Guide and its contents

Please respond to the following questions about your background:

Item	Response Option
Background Information
What is your gender?	Male Female
Which of the following best describes you? Select all that apply.	American Indian or Alaskan Native Asian or Pacific Islander Black or African American White or Caucasian Other
How long have you been involved with your coalition’s efforts to develop the Second Decade Community Action Plan?	Less than 1 month 1 to 6 months 7 to 10 months Don’t know Not applicable
Are you Hispanic or Latino?	Yes No
What is your primary role with the coalition?	Leadership (chair/vice chair, board member, or other elected role) Committee/sub-committee member lead or chair Community champion Individual contributor (e.g. general member, connect group to resources, content reviewer, etc.) Other
How long have you been involved with the host agency’s broader coalition’s efforts?	Less than 1 month 1 to 6 months 7 to 12 months 1 to 2 years 3 to 5 years More than 5 years Don’t know Not applicable
Did you receive a copy of the complete Guide (hard-copy or electronic)?	Yes No
Did you receive a copy of sections of the Guide (hard-copy or electronic)?	Yes No
If yes, please specify the sections of the Guide that you received?	(Indicate sections of the Guide – Open Text Response)
How was your participation in the coalition initiated?	A small leadership team contacted me directly about joining the coalition Someone at my agency (besides me) was contacted directly about the coalition I, or someone at my agency, reached out to other organizations to form a coalition I, or someone at my agency, responded to a posting/call for coalition members I was already involved with the agency leading the effort Other, please specify: Don’t know
Approximately how many hours a month do you, or someone from your agency, dedicate to coalition required activities such as regularly scheduled meetings?	Indicate number of hours
Which of the following best describes the sector that you or your organization represents on the coalition? Select one	Education Health or healthcare State or local government Elected officials (such as mayors, city council members, and school board members) Religion/faith-based Communications or media Social services or a youth-serving organization Non-profit organization Community-based organizations Tribal organization City planner General community member Youth volunteer Other (Please specify)

Do you have any other comments or feedback on the Guide? Please specify below.

Thank you for your participation!

ICF International 6

Attachment F – Coalition Assessment Survey