Northwestern Prevention Collaborative Community Survey Question Title * 1. What is your ethnicity? (Please select all that apply.) American Indian or Alaskan Native Asian or Pacific Islander Black or African American Hispanic or Latino White / Caucasian Prefer not to answer Other (please specify) OK Question Title * 2. What is your gender? Female Male OK Question Title * 3. How old are the children in your household? Under 5 6-11 12-18 19-20 N/A OK Question Title * 4. Which best describes your household? Two parent household Single parent household Parent & Step-parent Other (please specify) OK Question Title * 5. Are you employed? Yes, full-time Yes, part-time No OK Question Title * 6. What is your educational level? High School Graduate College Graduate Other (please specify) OK Question Title * 7. County of Residence? Warren County Shenandoah County Page County Frederick County Clarke County Winchester City OK Question Title * 8. Select the top FIVE problems you see as challenges in your county of residence. Academic Failure Alcohol Use (includes beer, wine, liquor) Assaults (fights) Bullying Curfew Violations (Out past legal time) Dating Driving Under the Influence Family Problems Gang Activity Marijuana Use Mental Health Problems Pregnancy and Teen Parenting Property Damage and Vandalism Run Away School Dropout Sexual Assults (including harassment and rape) Stalking Speeding and Traffic Violations Suicide/Depression Underage Drinking Tobacco Use (includes e-cigarettes, smokeless) Truancy (skipping school) Unhealthy relationships Heroin Use Prescription Drug Abuse/Misuse Underage Tobacco Use (includes e-cigarettes, smokeless) Other Drugs (please specify) OK Question Title * 9. Please select the top FIVE factors that contribute to the challenges identified in question 8. Adults provide alcohol to youth Adults provide other drugs to youth Adults provide tobacco to youth Illegal activities not reported Community denial of dangerous behaviors Easy availability of substances Judges not following through with consequences "Kids will be kids" attitude by adults Lack of adult supervision Lack of community education and awareness Lack of consistent enforcement of laws Lack of drug free alternatives for youth Lack of funding for "community coalition" and prevention work Lack of mental health and substance abuse treatment resources No sense of belonging Parents unaware of laws Peer pressure School policies not consistently followed Youth surrounded with positive images of dangerous behaviors Substance use as a coping mechanism Other (please specify) OK Question Title * 10. Which of the following organizations are you familiar with? Page Alliance for Community Action (PACA) Warren Coalition Family Youth Initiative (FYI) Community and Law Enforcement Against Narcotics (CLEAN Inc.) OK Question Title * 11. Do you know of additional organizations that address substance abuse? Yes No Other (please specify) If YES please list name of organization OK Question Title * 12. Have you seen/heard substance abuse prevention messaging in your community? Yes No OK Question Title * 13. If you answered YES to question 12 please select all that apply. TV Radio Billboard Print Social Media Movie Theater Other (please specify) OK Question Title * 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. OK DONE