Appendix B: Brainstorming Influencing Factors
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
Retail Access/ Availability
4. _____________ _________________ _____________
7._______________ _____________ _______________ 8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
27
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
7._______________ _____________ _______________
Social Access/ Availability
4. _____________ _________________ _____________
8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
28
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
7._______________ _____________ _______________
Enforcement of Laws and Policies
4. _____________ _________________ _____________
8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
29
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
7._______________ _____________ _______________
Community Norms
(perceived and actual)
4. _____________ _________________ _____________
8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
30
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
7._______________ _____________ _______________
Promotion of Alcohol Products
4. _____________ _________________ _____________
8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
31
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
Pricing of Alcohol Products
4. _____________ _________________ _____________
7._______________ _____________ _______________ 8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
32
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
7._______________ _____________ _______________
4. _____________ _________________ _____________
Pro-Social Involvement
8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
33
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
7._______________ _____________ _______________
4. _____________ _________________ _____________
Academic Achievement
8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
34
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
7._______________ _____________ _______________
4. _____________ _________________ _____________
Family Involvement
8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
35
County Name: Person Completing Form: Completion Date:
List POSSIBLE factors that contribute to each influencing factor:
1._______________ _____________ _______________
5._______________ _____________ _______________
2. _____________ _________________ _____________
6. _____________ _________________ _____________
3._______________ _____________ _______________
7._______________ _____________ _______________
Other
4. _____________ _________________ _____________
8. _____________ _________________ _____________
Major Community Barriers 1.__________________________ ___________________________
2.__________________________ ___________________________
3.__________________________ ___________________________
4.__________________________ ___________________________
Modified from Hornby Zeller Associates, Inc
36