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* 1. How old are you?

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* 2. What is your gender?

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* 3. Which race/ethnicity best describes you? (Select only one options)

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* 4. What is the highest level of education you have completed?

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* 5. What is the zip code where you live?

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* 6. Do you think substance use is a serious problem for adults in your community?

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* 7. Do you think substance use is a serious problem for youth in your community?

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* 8. Which substances do you worry about the most (choose your top 2 answers)

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* 9. Do you know anyone who has misused prescription medication?

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* 10. If you answered yes to the last question (number 9), do you think it was on purpose?

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* 11. Do you have family or friends who have suffered from a substance
use problem in the last five years?

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* 12. How often do you think friends or family are harming themselves
from the use of the following substances?

  Daily Sometimes Rarely Never
Alcohol
Marijuana
Prescription Medication like Valium or Xanax
Opioids like Hydrocodone, Oxycontin, Vicodin, Fentanyl
Stimulants like Ritalin or Adderall
Cocaine
Meth

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* 13. Have any of your friends or family gotten help with a substance
use problems?

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* 14. Out of the items listed below what are the three most difficult
challenges people face when trying to get help with substance use
prevention, education, treatment and recovery?(Pick 3)

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* 15. What do you think are the three biggest reasons people in our
community overuse substances? (Pick 3)

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* 16. Enter your telephone number if you want to be entered in a drawing for a $25 gift card.  Only those with a completed survey are eligible.
Your telephone number will only be used to contact you if you are a winner, it will not be shared, or used for any other purpose.

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