What is your ethnicity? (Please select all that apply.)

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* 1. What is your ethnicity? (Please select all that apply.)

What is your gender?

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* 2. What is your gender?

How old are the children in your household?

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* 3. How old are the children in your household?

Which best describes your household? 

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* 4. Which best describes your household? 

Are you employed? 

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* 5. Are you employed? 

What is your educational level? 

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* 6. What is your educational level? 

County of Residence?

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* 7. County of Residence?

Select the top FIVE problems you see as challenges in your county of residence.

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* 8. Select the top FIVE problems you see as challenges in your county of residence.

Please select the top FIVE factors that contribute to the challenges identified in question 8. 

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* 9. Please select the top FIVE factors that contribute to the challenges identified in question 8. 

Which of the following organizations are you familiar with? 

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* 10. Which of the following organizations are you familiar with? 

Do you know of additional organizations that address substance abuse?

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* 11. Do you know of additional organizations that address substance abuse?

Have you seen/heard substance abuse prevention messaging in your community?

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* 12. Have you seen/heard substance abuse prevention messaging in your community?

If you answered YES to question 12 please select all that apply. 

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* 13. If you answered YES to question 12 please select all that apply. 

If you would like more information on how the coalition in your community is working to prevent youth substance abuse OR if you would like to be placed in a random drawing for a gift card, please include your name and email address.  

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* 14. If you would like more information on how the coalition in your community is working to prevent youth substance abuse OR if you would like to be placed in a random drawing for a gift card, please include your name and email address.  

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