DFC Parent Survey REVISED 3/3/2016

This survey is designed to learn about your perceptions and attitudes that relate to underage use of alcohol and prescription drugs misuse and abuse. Your participation in this survey is very valuable and will help in finding positive ways to prevent underage drinking and prescription drug abuse and misuse in our community. It should take less than 5 minutes to complete. If you do not wish to respond to a question, simply leave it blank. You will not be asked to provide your name, and survey responses will only be presented in aggregate form. Thank you for your time!

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* 1. Date

Date

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* 2. Location

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* 3. Your Age

Under 25

25-34

35-44

45-54

55-64

65 yrs or older

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* 4. Your Gender

Female

Male

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* 5. Your Zip Code:

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* 6. Your Race (please choose one category):

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Other

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* 7. Please check all that apply if you are:

Parent, stepparent or legal guardian of a child (children) between the ages of 12 and 25

Teacher

Administrator in an agency or organization that provides services to children, youth and families

Other (please specify)

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* 8. If you are a parent, stepparent or legal guardian of a child (children), how many children between the ages of 12 and 25 do you have?

5 or more

I do not have a children between the ages of 12 and 25

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* 1. Date

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* 2. Location

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* 3. Your Age

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* 4. Your Gender

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* 5. Your Zip Code:

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* 6. Your Race (please choose one category):

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* 7. Please check all that apply if you are:

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* 8. If you are a parent, stepparent or legal guardian of a child (children), how many children between the ages of 12 and 25 do you have?

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* 9. What are their ages (only check ages of your children between the ages of 12 and 25)?