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.  You will receive a small prize as a thank you for your time.
 
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.  

Question Title

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

Question Title

* 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)

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

T