* 1. Zip Code

* 2. I have children in the following age ranges (check all that apply):

* 3. When was the last time you talked with your child about attending parties where alcohol was available or being served to teens?

* 4. How big of a problem would you say that youth alcohol use is in our community?

* 5. If your underage child was asked to attend a friend's un-chaperoned party where alcohol was going to be available or served, how likely is it that you would let him/her go?

* 6. If your underage child was asked to attend a friend's chaperoned party where alcohol was going to be available or served, how likely is it that you would let him/her go?

* 7. How upset would you be if your underage child was caught drinking?

* 8. How upset would you be if your underage child was caught using drugs?

* 9. I would allow my child and my underage child's friends to drink in my home as long as I took the keys and felt that "everyone was safe in my home".

* 10. I would like a local option to drug test my child at my request. 

* 11. I am aware that there are free home drug testing kits available in our community.

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