INTRODUCTION

Wilder Research is working with the Department of Human Services Alcohol and Drug Abuse Division to provide assessment and evaluation support for the Strategic Prevention Framework State Incentive Grant (SPF SIG). Part of this is assessment is to gain an understanding of the prevention infrastructure within funded communities. This questionnaire is designed to gather some brief information about the types of prevention services, experience, capacity, and resources your agency has. Please take a few minutes to complete this and return it via email to Kristin Dillonat . Thank you.

COMMUNITY/COALITION

1.Name of agency:

2. Location of agency (city):

3.Agency’s annual budget for the current fiscal year:

4.Area/region agency serves (i.e., counties, major towns, etc.):

5.Please describe your agency’s current prevention activities, including both ATOD-related and other prevention activities, such as efforts to reduce teen pregnancy, traffic accidents, school suspensions, expulsions,ortruancy.

Program / service name / Year
started / Level of implementation
(Check all that apply) / Currently evaluated? / Evidence based?
Individual level Family level
School level Community level / Yes
No / Yes
No
Don’t Know
Individual level Family level
School level Community level / Yes
No / Yes
No
Don’t Know
Individual level Family level
School level Community level / Yes
No / Yes
No
Don’t Know
Individual level Family level
School level Community level / Yes
No / Yes
No
Don’t Know
Individual level Family level
School level Community level / Yes
No / Yes
No
Don’t Know
Individual level Family level
School level Community level / Yes
No / Yes
No
Don’t Know
Individual level Family level
School level Community level / Yes
No / Yes
No
Don’t Know

PREVENTION RESOURCES

6.How many people does your agency have working in each of the following capacities?

Number of people / Number of FTEs or full-time equivalents
Paid staff at your agency (total)
Paid staff working on ATOD prevention
Paid staff working on SPF-SIG
Unpaid volunteers or interns working on SPF-SIG

7.How many of your agency’s paid employees have the following training?

Substance Abuse Prevention Specialist Training (SAPST):

Credentialed as a Certified Prevention Professional or higher:

Other prevention training: Please specify:

Other substance abuse training: Please specify:

8.Besides the current SPF-SIG grant, what prevention funding has your agency received in the last five years? [Please include funding for ATOD-related and otherprevention activities, such as efforts to reduce teen pregnancy, traffic accidents, school suspensions, expulsions, or truancy.]

Source / Dates / Amount / Purpose

9.How has your agency used other resources, such as meeting spaces, technology, or partnerships, to support your prevention efforts?

10.Please describe any prevention-related research your agency has conducted in the last five years.
[Include needs assessments, evaluations of any prevention programs or services, or other research your agency has conducted related to prevention.]

Description / Date completed / Are key findings available?
(If yes, please attach)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

11.Please describe any prevention-related community coalitions, taskforces, or other collaborative groups in which your agency has participated in the last five years.

Name of group / Description of group (goals, activities, mission, vision) / Dates your agency participated / Total number of participants in group / Number of your employees
in group

SPF SIG Agency Survey1Wilder Research, March 2012