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

* 2. What is your gender?

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

* 4. Which best describes your household? 

* 5. Are you employed? 

* 6. What is your educational level? 

* 7. County of Residence?

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

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

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

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

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

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

* 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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