PREFERRED ROLE Boards/Workgroups Duties/Skills Key Leader Board Engage other leaders Oversee implementation of the process Hold the Community Board accountable Community Board Coordinate work-group activities Participate in decision-making Communicate with Executive Committee Executive Committee Set agendas Provide oversight Report to Key Leader Board Risk and Protective Factor Workgroup Collect and analyze data Facilitate prioritization of needs Report findings Community Outreach and Public Relations Workgroup Maintain contact with stakeholders Educate and involve community members Work with the media and distribute the report/plan Youth Involvement Workgroup Identify and involve existing youth groups Recruit youth to serve on Boards/Workgroups Coordinate skills development and recognition Resources Assessment and Evaluation Workgroup Inventory existing prevention efforts Identify gaps Design the evaluation of the plan Funding Workgroup Identify resources and sources of funding Write grant proposals Community Board Maintenance Workgroup Establish communication and reporting protocols Establish by-laws, operating procedures, & fiscal/legal status Recruit and educate new Community Board members AGENCY INFORMATION Agency Name: Address: Phone: Web Address: Please list each of your agency’s programs, policies or practices related to substance abuse. Indicate the risk/protective factor that it addresses and how the factor is addressed.
DATE SCHOOL / AGENCY / ORGANIZATION / HOSPITAL ADDRESS COALITION ADDRESS To Whom It May Concern: This letter is authorization for the coalition to use the SCHOOL / AGENCY / ORGANIZATION / HOSPITAL DATA for YEAR-YEAR. We understand that: These data will be used for a COUNTY needs assessment and strategic plan. De-identified data will be provided to the coalition implementing Communities That Care (CTC) and Indiana Prevention Resource Center staff only after it has been released to the school. Data will be aggregated to avoid identification of individuals. Secondary analysis of these data may be conducted for research purposes with prior approval from an institutional review board. A copy of the needs assessment and strategic plan may be provided to each SCHOOL / AGENCY / ORGANIZATION / HOSPITAL’s designated representative upon request. The report will be distributed throughout the community and state, which may include distribution by media outlets and inclusion in other public documents. The report may be used to procure grant funds. SCHOOL / AGENCY / ORGANIZATION / HOSPITAL representatives are welcome to be members of the coalition. Sincerely, _____________________________________________ SCHOOL / AGENCY / ORGANIZATION / HOSPITAL REPRESENTATIVE _____________________________________________ Community Coordinator Sample Emergency Preparedness Plan Introduction:
Determinants are factors that contribute to or cause a health behavior to occur. Determinants can be contributing factors, risk factors, or protective factors. Many risk and protective factors can be measured via the . Contributing Factors: Contributing Factors are attitudes, behaviors, and other characteristics associated with a likelihood of the health behavior. Contributing Factors Visible enforcement Laws Community norms Promotion Price Retail Availability ( and ) Social availability Use beliefs Family, school, and peer influence Context Perceived risk of arrest Community concern about harm Risk Factors (Youth): Risk factors are characteristics of an individual, family, school, or community environment that are associated with increases in the development of problem behaviors (alcohol and other drug use, delinquency, teen pregnancy, school dropout and violence) among youth and adolescents. Community (C) Family (F) School (S) Individual/Peer (IP) Availability of drugs Availability of firearms Community laws and norms favorable toward drug use, firearms, and crime Media portrayals of violence Transitions and mobility Low neighborhood attachment and community disorganization Extreme economic Family history of the problem behavior Family management problems Family conflict Favorable parental attitudes and involvement in the problem behavior Academic failure beginning in late elementary school Lack of commitment to school Early and persistent antisocial behavior Rebelliousness Friends who engage in the problem behavior Favorable attitudes toward the problem behavior Early initiation of the problem behavior Constitutional
Description - What needs to be sustained? Desired Outcomes - What are the desired outcomes that will be achieved? Action Steps - What actions need to be taken to achieve the outcomes? Rationale - Why is it needed? - Benefits to the coalition/community: - Harm if Lost/Not achieved: Partners - What partners need to be involved? - What partners will benefit? Human Personnel Time Skills Experience Leadership Ideas Social Connections Relationships Agreements Social networks Material Supplies Office/Meeting Space Transportation Technology Communication Money Share Asset Sharing In-Kind Contributions Leveraging Shared Positions Incorporate strategies into host organizations Ask Grants Fundraisers Individual/Business Donations United Way / Payroll Giving Endowed Funds / Planned Giving Online Giving Charge Fee for Service Fine / Penalty Revenue to Prevention Line Item in Budget City/County Prevention Budget Other CBO/NPO’s Budget Membership Dues Acquiring Tax Revenues Earn Entrepreneur Activity Business Plan Partial Ownership of For-Profit Enterprises Coalition Case Statement Example Coalition Case Statement
The next few questions ask about your use of and attitudes toward tobacco, alcohol, and other substances. back over the past 30 days and report how many times, if any, you used the following substances: Never 1-5 Times 6-19 Times 20-39 Times 40 Times or More Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes During the past 30 days, how many times did you smoke part or all of a cigarette? Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe During the past 30 days, how many times did you use other tobacco products? Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor During the past 30 days, how many times did you drink one or more drinks of an alcoholic beverage? Marijuana or hashish: Also known as grass, pot, hash, or hash oil During the past 30 days, how many times did you use marijuana or hashish? Methamphetamine: It is a highly addictive stimulant, also known as meth, crystal, ice or speed During the past 30 days, how many times did you use methamphetamine? Cocaine or crack cocaine: A highly addictive stimulant, also known as coke, snow or smack (usually a white powder) During the past 30 days, how many times did you use crack or crack cocaine? Heroin: A highly addictive drug that relieves pain (usually injected) During the past 30 days, how many times did you use heroin? Hallucinogens: Drugs that cause people to see or experience things that are not real, such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust) During the past 30 days, how many times did you use any hallucinogens?
No Risk Slight Risk Moderate Risk Great Risk Don’t Know or Can’t Say When they smoke one or more packs of CIGARETTES per day? When they smoke MARIJUANA once or twice a week? When they use cocaine once or twice a week? When they use methamphetamine once or twice a week? When they have five or more drinks of an ALCOHOLIC BEVERAGE once or twice a week? This section asks just a few additional questions about your attitudes and experiences. Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you? (Check one) More Likely Less Likely Would Make No Difference Don’t Know or Can’t Say Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you? (Check one) More Likely Less Likely Would Make No Difference Don’t Know or Can’t Say DURING THE PAST 12 MONTHS, have you driven a. vehicle while you were under the influence of alcohol? Yes No Don’t Know or Can’t Say Now think about the past 12 months through today. DURING THE PAST 12 MONTHS, how many times have you talked with your child about the dangers or problems associated with the use of tobacco, alcohol, or drugs? Don’t have any children 0 times 1 to 2 times A few times Many times Don’t know or can’t say During the past 12 months, do you recall hearing, reading, or watching an advertisement about prevention Yes No
any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe how many times did you use other tobacco products? Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor During the past 30 days, how many times did you drink one or more drinks of an alcoholic beverage? Marijuana or hashish: Also known as grass, pot, hash, or hash oil During the past 30 days, how many times did you use marijuana or hashish? Methamphetamine: It is a highly addictive stimulant, also known as meth, crystal, ice or speed During the past 30 days, how many times did you use methamphetamine? Cocaine or crack cocaine: A highly addictive stimulant, also known as coke, snow or smack (usually a white powder) During the past 30 days, how many times did you use crack or crack cocaine? Heroin: A highly addictive drug that relieves pain (usually injected) During the past 30 days, how many times did you use heroin? Hallucinogens: Drugs that cause people to see or experience things that are not real, such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust) During the past 30 days, how many times did you use any hallucinogens? Inhalants or sniffed substances: Such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish During the past 30 days, how many times did you use inhalants? Prescription drugs without a doctor’s orders: Just to get high During the past 30 days, how many times did you use prescription drugs without a prescription?
Think back over your entire lifetime and try to remember whether you have EVER used any of the following substances. If so, what was your age the FIRST TIME you used the substance: Never Used 10 or Younger 11 12 13 14 15 16 17 or Older Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes Ever smoked part or all of a cigarette? Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe Ever used any other tobacco product? Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor Ever had a drink of an alcoholic beverage? Do NOT include any time when you only had a sip or two from a drink. Marijuana or hashish: Also known as grass, pot, hash, or hash oil Ever used marijuana or hashish? Methamphetamine: A highly addictive stimulant, also known as meth, crystal, ice or speed Ever used Cocaine or crack cocaine: A highly addictive stimulant, also known as coke, snow or smack (usually a white powder) Ever used cocaine? Heroin: A highly addictive drug that relieves pain. (usually injected) Ever used heroin?
CTC Risk and Protective Factor Scales Instructions: Mark the Big “NO!” if you think the statement is definitely not true for you. Mark the little “no” if you think the statement is mostly not true for you. Mark the little “yes” if you think the statement is mostly true for you. Mark the Big “YES!” if you think the statement is definitely true for you. Family Attachment Do you feel very close to your mother? NO! no yes YES! Do you share your thoughts and feelings with your mother? NO! no yes YES! Do you feel very close to your father? NO! no yes YES! Do you share your thoughts and feelings with your father? NO! no yes YES! Family Opportunities for Prosocial Involvement My parents give me lots of chances to do fun things with them. NO! no yes YES! My parents ask me what I think before most family decisions affecting me are made. NO! no yes YES! If I had a personal problem, I could ask my mom or dad for help. NO! no yes YES! Family Rewards for Prosocial Involvement My parents notice when I am doing a good job and let me know about it. Never or almost never Sometimes Often All the time How often do your parents tell you they’re proud of you for something you’ve done. Never or almost never Sometimes Often All the time Do you enjoy spending time with your mother? NO! no yes YES! Do you enjoy spending time with your father? NO! no yes YES!