Substance Use Survey

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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:

Less than High School degree

High School Degree/GED

Some College

Associate’s Degree

Undergraduate Degree

Graduate Degree

Technical Certification/Degree

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

Healthcare/Social Services

Agriculture

Education

Sales

Student

Skilled Labor

Law/Criminal Justice/Government

Retail/Food Service

Other (please specify)

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* 9. What is your current employment status?

Employed Full-time

Employed Part-time

Unemployed

Retired

Disabled

Other (please specify)

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* 10. What is your annual income?

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* 11. Which BEST describes you?

Generally, my mental health is good

I sometimes struggle with my mental health but I do not have a mental health diagnosis.

I often struggle with my mental health but I do not have a mental health diagnosis.

I have a mental health diagnosis (e.g. anxiety, depression, etc.) but I am not currently in treatment/counseling.

I have a mental health diagnosis (e.g. anxiety, depression, etc.) and I am currently being treated for it/in counseling.

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

I do not use substances like cocaine, marijuana, heroin, meth, etc.

I sometimes experiment with substances like cocaine, marijuana, heroin, meth, etc.

I often use substances like cocaine, marijuana, heroin, meth, etc.

I have a diagnosed substance use disorder, but I am not in treatment.

I have a diagnosed substance use disorder and I am currently in treatment for substance use.

I am in recovery for substance use.

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

Yes

Not sure

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

Yes

Not sure

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

Yes

Not sure

I do not have a primary care provider/doctor.

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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).

Yes

Not sure

I do not have a primary care provider/doctor.

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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.

Strongly agree

Somewhat agree

Unsure

Somewhat disagree

Strongly Disagree

I do not have a primary care provider/doctor.

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

Marijuana

Heroin

Cocaine

Methamphetamine (Meth)

Prescription pain killers (e.g. hydrocodone, Vicodin, Oxycontin)

Other (please specify)

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

Strongly agree

Somewhat agree

Unsure

Somewhat disagree

Strongly Disagree

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

Strongly agree

Somewhat agree

Unsure

Somewhat disagree

Strongly Disagree

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

Strongly agree

Somewhat agree

Unsure

Somewhat disagree

Strongly Disagree

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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.

Strongly agree

Somewhat agree

Unsure

Somewhat disagree

Strongly Disagree

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

Very Active

Somewhat Active

Every once in a while

Rarely

Not at all

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

Strongly agree

Somewhat agree

Unsure

Somewhat disagree

Strongly Disagree

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

Strongly agree

Somewhat agree

Unsure

Somewhat disagree

Strongly Disagree

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

Other (please specify)