You are being invited to take part in an evaluation of opioid prevention efforts 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 ten 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.

By completing this questionnaire, you are indicating that you have read and agree with this consent form.  

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* 1. Prior to today, have you seen or heard any of the following features of the Prescribe Change campaign? (Check all that apply)

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* 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)

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* 3. Have you taken medication(s) to a drop-off box within the past 12 months? (Check only one)

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* 4. If you have not used a medication drop box, then why not?

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* 5. Do you currently secure household's medications in a locked location? (Check only one)

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* 6. If you do not currently secure your medications in a locked location, then why not?

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* 7. Have you shared information about opioids with other people that you know within the past 12 months?  (Check only one)

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* 8. Prior to today, were you aware of free Naloxone (Narcan) training? (Check only one)

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* 9. Which of the following best describes your employment status? (Optional - Check all that apply)

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* 10. What is the highest level of education you have completed?  (Optional - Pull down the arrow and highlight your answer)

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* 11. What is the your age? (Optional - Check only one)

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* 12. What is your gender? (Optional - Check only one)

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* 13. Which race/ethnicity best describes you? (Optional - Check only one)

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