This survey…

·         Will ask questions about your use of prescription drugs, alcohol and other drugs.

·         Results will be used to help inform and improve prevention programs.

·         Is completely voluntary.  You may skip any question that you are not comfortable with.

·         Is completely anonymous.  We are not asking your name or other identifying information.

·         There are 48 questions, and it should take you approximately 10-15 minutes to complete.

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* 1. Are you:

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* 2. What is your age:

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* 3. Which best describes your ethnicity?

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* 4. What is your employment status?

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* 5. Are you a Veteran?

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* 6. Are you currently a student?

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* 7. What is your highest level of education?

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* 8. What is the zip code of the town or city where you live? __________________

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* 9. How easy do you think it is for persons your age in your community to obtain prescription pain relievers (such as OxyContin, Percocet, Vicodin, Hydrocodone, or Tylox) that were not prescribed to them?

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* 10. How easy do you think it is for persons your age in your community to obtain prescription stimulant pills (such as Ritalin, Adderall, or Concerta) that were not prescribed to them?

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* 11. How easy do you think it is for persons your age in your community to obtain prescription tranquilizers or “benzos”, (such as Xanax, Valium, or Ativan) that were not prescribed to them?

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* 12. How easy do you think it is for persons your age in your community to obtain recreational marijuana?

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* 13. How easy do you think it is for persons your age in your community to obtain heroin?

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* 14. How easy do you think it is for persons your age in your community to obtain any other drug?
(Please enter other drug below)

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* 15. How much do people risk harming themselves physically and/or in other ways when they smoke one or more packs of cigarettes per day?

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* 16. How much do people risk harming themselves physically and/or in other ways when they use an e-cigarette or other vaping device?

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* 17. How much do people risk harming themselves physically and/or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?

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* 18. How much do people risk harming themselves physically and/or in other ways when they use prescription pain relievers that are not prescribed to them?

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* 19. How much do people risk harming themselves physically and/or in other ways when they use prescription stimulants that are not prescribed to?

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* 20. How much do people risk harming themselves physically and/or in other ways when they use prescription tranquilizers that are not prescribed to them?

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* 21. How much do people risk harming themselves physically and/or in other ways when they use recreational marijuana?

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* 22. How much do people risk harming themselves physically and/or in other ways when they use heroin?

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* 23. How do you feel about someone your age smoking cigarettes?

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* 24. How do you feel about someone your age using e-cigarettes or a vaping device?

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* 25. How do you feel about someone your age having one or two drinks of an alcoholic beverage every day?

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* 26. How do you feel about someone your age driving after one or two drinks?

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* 27. How do you feel about someone your age smoking recreational marijuana?

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* 28. How do you feel about someone your age using prescription pain relievers that are not prescribed to them?

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* 29. How do you feel about someone your age using prescription stimulants that are not prescribed to them?

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* 30. How do you feel about someone your age using prescription tranquilizers that are not prescribed to them?

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* 31. How do you feel about someone your age using heroin?

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* 32. During the past 30 days, how many days did you smoke part or all of a cigarette?  

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* 33. During the past 30 days, how many days did you use e-cigarettes or a vaping device?

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* 34. During the past 30 days, how many days did you drink one or more drinks of an alcoholic beverage?

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* 35. During the past 30 days, how many days did you have 5 or more drinks on the same occasion?

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* 36. During the past 30 days, how many days did you use prescription pain relievers (such as OxyContin, Percocet, Vicodin, or Tylox) that were not prescribed to you?

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* 37. During the past 30 days, how many days did you use prescription stimulants (such as Ritalin, Adderall, or Concerta) that were not prescribed to you?

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* 38. During the past 30 days, how many days did you use prescription tranquilizers or “benzos”, (such as Xanax, Valium, or Ativan) that were not prescribed to you?

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* 39. During the past 30 days, how many days did you use recreational marijuana?

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* 40. During the past 30 days, how many days did you use heroin?

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* 41. If you used prescription drugs such as pain relievers, stimulants or tranquilizers that were not prescribed to you, how did you get them?

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* 42. During the past 12 months, have you experienced any of the following due to your use of alcohol? (Check all that apply)

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* 43. During the past 12 months, have you experienced any of the following due to your use of marijuana?  (Check all that apply)

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* 44. During the past 12 months, have you experienced any of the following due to your use of prescription pain relievers ?  (Check all that apply)

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* 45. During the past 12 months, have you experienced any of the following due to your use of other prescription drugs?  (Check all that apply)

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* 46. During the past 12 months, have you experienced any of the following due to your use of heroin?  (Check all that apply)

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* 47. Do you know where to get help if you’re having concerns with a person’s use of alcohol, marijuana or other drugs?

For more information on underage drinking/drug abuse and where to go for help, please call the Steuben Prevention Coalition or Steuben Council on Addictions at (607)-776-6441 or just dial 2-1-1 for the HELPLINE.  For online information, visit the following websites… http://www.2111helpline.org/find-help, www.drugfree.org, www.drugabuse.gov, and www.timetotalk.org.
This is the end of the survey, thank you for taking the time to provide your input, it is greatly appreciated!

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