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This survey is intended to understand the perceptions of community members around substance use.  Information will be used to understand the environment and needs in your county.  This research is sponsored through federal funding from the Health Resources and Services Administration (HRSA). Your participation in this survey is voluntary and your responses are anonymous.  It will take about 10-15 minutes to complete.  To participate, you must be at least 18 years old.  If you have any questions you can contact cmullen@indianarha.org

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* 1. What is your gender (woman, man, transgender, etc.)?

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* 2. What is your age?

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* 3. What is your race/ethnicity (African American, Asian, White, Latinx, etc.)?

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* 4. What is your relationship status (Single, Married, Widowed/Divorced, Committed Relationship, etc.)?

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* 5. What county do you currently live in?

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* 6. How many people live in your immediate household?

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* 7. Select your highest level of education:

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* 8. Which of the following best represents your current occupation? (select 1)

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* 9. What is your current employment status?

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* 10. What is your annual income?

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* 11. Which BEST describes you?

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* 12. Excluding alcohol and tobacco, which of the following BEST describes you?

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* 13. I have/had a close relationship with someone who has struggled with substance use.

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* 14. I have used medications more often than they were prescribed or when they were not prescribed for me.

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* 15. My primary care provider/doctor has talked with me about substance use.

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* 16. I have responded to questions about using tobacco, alcohol, and drugs at my primary care provider/doctor’s office (by talking with my doctor or filling out a paper or online form).

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* 17. If I ever needed help for substance use, I would be comfortable talking with my primary care provider/doctor for help.

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* 18. Excluding alcohol and tobacco, which of the following is the biggest drug problem in your county? [Select one]

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* 19. My county has a growing problem with the use of substances like cocaine, marijuana, heroin, meth, etc.

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* 20. My county has the resources to effectively address the use of substances like cocaine, marijuana, heroin, meth, etc.

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* 21. The use of substances like cocaine, marijuana, heroin, meth is being addressed effectively in my county.

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* 22. The use of substances like cocaine, marijuana, heroin, meth, etc. is a temporary problem in my county that will go away on its own.

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* 23. How active are you in a church/faith community?

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* 24. My church/faith community is welcoming/non-judgmental of people who engage in substance use.

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* 25. My faith community supports people with substance use problems by connecting them to community resources.

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* 26. How much of a barrier would each of the items below be if you ever needed to get treatment for substance use?

  Not at all Not really Unsure Somewhat Very much
Fear of losing my family (e.g. partner, children)
Fear of losing my job
Fear of going to jail/prison
Others' judgment of me/Stigma
My own self-judgment/Shame
Cost/Lack of health insurance
Lack of transportation
Lack of treatment options
Lack of privacy/confidentiality
Lack of childcare
Not knowing where to go for help

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