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Questionnaire for Opioid Education

You are being invited to take part in an evaluation of prevention efforts and education that are coordinated by the Allegany County Health Department. Your responses will help us improve our efforts to prevent the misuse and abuse of opioids. Your participation is completely voluntary. You may decline to answer any question and you may withdraw from the survey at any time. All of your responses will be confidential and anonymous. No personal identifying information will be collected from you. The questionnaire takes approximately two minutes to complete.

If you have any questions about your rights as a participant, or if you think you have not been treated fairly, you may call Gay Hutchen at the Maryland Department of Health Institutional Review Board (IRB) at 410-767-8488 and reference the Allegany County Prevention Program or call Jordan Harman, the Prevention Director and the Allegany County Health Department, at 301-759-5050.

By completing this questionnaire, you are certifying that you are 18 years of age or older and that you have read and agree with this consent form.
1.Prior to today, have you seen or heard any of the following features of the Prescribe Change campaign? (Check all that apply)
2.Prior to today, have you heard about the medication drop-off boxes where you can safely dispose of unused prescription medications? (Check only one)
3.Have you taken medication(s) to a drop-off box within the past 12 months? (Check only one)
4.Are you able to identify at least one of the medication drop-off locations? (Check only one)
5.Prior to today, have you heard about the medication disposal bags (Deterra®) that you can safely dispose of medication at home? (Check only one)
6.Do you currently secure your household's medications in a locked location? (Check only one)
7.Do you currently store medical marijuana in a locked location? (Check only one)
8.Have you shared information about prescription opioids, marijuana and/or other medications with other people that you know within the past 12 months? (Check only one)
9.Prior to today, were you aware of free Naloxone (Narcan) training? (Check only one)
10.Which of the following best describes your employment status? (Check all that apply)
11.What is the highest level of education you have completed?
12.What is the your age?
13.What is your gender? (Check only one)
14.Which race/ethnicity best describes you? (Check only one)