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* 1. What is your gender?

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* 2. What is your age?

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* 3. Which race/ethnicity best describes you? (Select all that apply)

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

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* 5. Are there children living in your household in these categories? (Select all that apply)

  Male Female Other Gender
High School
Middle School
Elementary School
Alternative School

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* 7. Have you heard of the Porter County Substance Abuse Council?

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* 8. How would you describe your alcohol use?

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* 9. In the past 30 days, how many times have you used alcohol?

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* 10. How likely is it that a child in your household has used alcohol in his/her lifetime?

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* 11. How likely is it that a child in your household has used alcohol in the last 30 days?

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* 12. How likely is it that a child in your household has used alcohol to the point of intoxication?

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* 13. How much does a person under the age of 18 risk harming themselves physically and in other ways if they...

  No risk Slight risk Moderate risk Great risk
Drink alcohol occasionally?
Have five or more drinks of an alcoholic beverage once or twice a week?
Have one or two drinks of an alcoholic beverage nearly every day?

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* 14. Describe how alcohol is stored in your home. (Check all that apply)

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* 15. How much do you agree or disagree with the following statements?

  Strongly Disagree Disagree Agree Strongly Agree Don't know
It is okay to allow someone under the age of 18 to drink alcohol while at home.
It is okay for someone under the age of 18 to drink under adult supervision.
If a child in my household drank alcohol without my permission, I would catch her/him.
I have a strong influence over the children in my household's behavior relating to alcohol use, and the rules in our family regarding alcohol use are clear.

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* 16. Do you think that talking to the children in your household about alcohol use is beneficial?

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* 17. How confident are you in being able to talk effectively with the children in your household about alcohol?

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* 18. During the past 12 months, how many times have you talked with the children in your household about the dangers or problems that could result from youth alcohol use?

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* 19. How much do you agree or disagree with the following statements?

  Strongly disagree Disagree Agree Strongly Agree Don't know
My community has a high acceptance for alcohol use.
Alcohol use is a big problem in my community by middle schoolers.
Alcohol use is a big problem in my community by high schoolers.
It is easy for underage youth to get alcohol in my community.

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