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This voluntary survey will take less than five minutes to complete.
Your responses will help guide us in building a healthy community. Thank you for your time!!!


We are required by the NJ Department Human Services and the U.S Department of Health and Human Services to collect the following demographic data. We would appreciate your cooperation in completing the following:

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* 1. What is your age?

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* 2. What is your Race/Ethnicity?

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* 3. What is your gender?

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* 4. What city do you live in? 

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* 5. What county do you live in?

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* 6. It is okay for parents and other adults to allow underage drinking in their home.

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* 7. It is okay to allow underage drinking in private homes as long as it is in a controlled setting (e.g. car keys are collected, designated drivers are assigned).

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* 8. I am aware of neighbors or other adults who allow underage drinking in their home.

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* 9. I allow underage drinking in my home.

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* 10. I monitor the amount of alcohol in my home on a regular basis.

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* 11. I believe that alcohol laws/regulations (e.g. carding for 21 at retail stores and bars) are enforced regularly in my community.

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* 12. I believe that alcohol is bad for an adolescent’s brain.

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* 13. I am aware of youth who use prescription drugs without a prescription.

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* 14. The proper way to dispose of prescription and/or over-the-counter drugs is by flushing them down the toilet.

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* 15. I monitor and secure the medications in my home.

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* 16. It is okay to take someone else’s prescription drug.

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* 17. It is okay to take someone else’s prescription drug.

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* 18. I know where to get information on alcohol, tobacco, and other drugs.

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* 19. If there was a local place to discard expired or unused medications at no cost, I would regularly use this service.

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* 20. I believe that marijuana can be just as harmful as alcohol.

If you are a parent, grandparent, or a guardian providing a home for a child/children under age 21, please answer the following questions:

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* 21. My family has dinner together regularly.

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* 22. I talk with my child(ren) about alcohol, drugs, and tobacco on a regular basis (at least several times per year).

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* 23. I have clear and specific rules about my child(ren)’s association with peers who use.

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* 24. I have children of the following ages (check all that apply)

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