Purpose: The Cumberland-Fayetteville Opioid Response Team (C-FORT) wants to know your thoughts about how struggles with opioids and other substances have affected or impacted your life, work and community. Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others. This survey data will be used to support C-FORT strategies, action plans, and activities for the upcoming year.

Directions: Answer the questions, based on you, your community and your lived experiences. There are no wrong answers. This survey should take no more than 3 to 5 minutes to complete.

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* 1. Do you agree or disagree with the following statement: I know how to recognize signs and symptoms of opioid abuse/misuse? (Check ONE box that applies)

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* 2. What impact has opioid misuse had on you or your family? (Check ALL that apply)

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* 3. Do you agree or disagree with the following statement: I am aware of resources in my community to assist people with an opioid problem. (Check ONE box that applies)

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* 4. If you were struggling with opioid misuse, who would you feel the most comfortable going to for help? (Check ALL that apply)

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* 5. In your opinion, what is the primary/main cause of dependence? (Check ALL that apply)

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* 6. Which methods of getting information do you currently use? (Check ALL that apply)

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* 7. When disposing of unused or expired medications, which method do you (or would you most likely) use? (Check ALL that apply)

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* 8. Do you agree or disagree with the following statement: I am familiar with Naloxone/Narcan/Evzio, what it is used for, and where I can obtain it? (Check ONE box that applies)

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* 9. Do you know where you, or someone you care about, can go to for help with reducing the use of opioids? (Check ONE box that applies)

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* 10. Have you or someone you know been charged with a crime related to any of the following? (Check ALL that apply)

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* 11. What is your age? (Check ONE that applies)

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* 12. What is your race? (Check ALL that apply)

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* 13. What is your gender? (Check ALL that apply)

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