Community Norms Regarding Prescription Medication

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1. Are you:

Are you:   Male Female

2. How would you describe your racial or ethnic background?

How would you describe your racial or ethnic background?   American Indian Asian Black or African American Caucasian Hispanic

Other (please specify)

3. How old are you?

How old are you?   18-20 21-24 25-44 45-64 65+

4. Do you live in Lac du Flambeau?

Do you live in Lac du Flambeau?   Yes

No

5. If yes, how long have you lived in Lac du Flambeau?

If yes, how long have you lived in Lac du Flambeau?   Less than one year One to two years Two to five years Five to 10 years Ten years or longer

6. If you have children 21 years of age or younger, how old are they? (Check all that apply.)

If you have children 21 years of age or younger, how old are they? (Check all that apply.)   I do not have children 21 years of age or younger 0-4 years 5-9 years 10-14 years 15-17 years 18-21 years Over 21 years

7. Regarding prescription medication, which of the following best describes you?

Regarding prescription medication, which of the following best describes you?   I take prescription medication occasionally when prescribed by Doctor for temporary illnesses I take prescription medication prescribed by a doctor regularly because of a chronic condition.