Coalition Member Assessment

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Please remember anyone can do prevention work! It is FUN!

This form will be used as a way to get to know our Coalition members. Please answer the questions below. If you have questions or concerns please reach out to nikki@ysainc.org or check out the website: www.ysainc.org/prevention-dfc

Coalition Purpose: Establish and strengthen collaboration among communities, public and private non-profit agencies, and Federal, state, local and tribal governments to support the efforts of community coalitions working to prevent and reduce substance use among youth.

Name and Contact Information (email/phone)

Date

YYYY

Age

11 -13

14-16

17-20

21-35

Other

Clear selection

What level of involvement would you like to have in the Substance Abuse Prevention Coalition?

Supportive member- would like to get emails, will share information, will promote coalition.

"Call-Me" member- when you have a specific need call me to help, will share information and help promote coalition.

Active member- will attend meetings (when able to), will try to help assist in coalition efforts.

Leading member- would like to represent a sector in the community, will lead tasks when needed

Other:

Clear selection

Work-Related Assessment

This series of questions should be answered based on your company/organization. If you are joining as an individual respond NA.

What is your role in the organization/company? What is your title?

What are your professional goals?

What are your greatest strengths at work? (Ex: organized, detail oriented, finance tracking, data collection, etc.)

What are the company/organizations goals?

Coalition related questions

This series of questions is based on your work within the Coalition.

Why do you want to volunteer/participate to be a part of this Coalition?

What opportunities do you hope to take advantage of? (ex: training, networking, leading, learning, mentoring, etc.) What role do you see yourself in?

What would make this sort of commitment easiest for you to participate? Are there any potential conflicts you might foresee in serving on the coalition over the next year?

If you are already attending meetings, what do you enjoy the most and the least about the coalition?

Self-Assessment

These questions are being asked about yourself on a personal level (not work related). Lets get to know you outside of work.

What do you enjoy doing in your free time?

What are your goals in life?

How do you think this coalition benefit you on a personal level?

Want to join an Action Workgroup/Team? These groups are topic specific and meet more often. If you'd like to learn more about any of them please choose which ones interest you.

Youth Empowerment

Data Collection

Training and Public Engagement

Tobacco Prevention Workgroup

Sustainability Workgroup

No thank you- large group only

Send me information on all of them, then you can choose.

Capacity Building and Training

Do you know any other co-workers, friends or acquaintances that would be passionate about working to develop a strong cohesive coalition? Anyone who would have an interest in helping our youth become active leaders in our community? Names and contact information can be provided to us and we can reach out or you can invite them to our next meeting.

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