Regional Prevention Partnerships
Alcohol and Other Drug Use Prevention: Collaborating with Law Enforcement Partners

Please tell us more about yourself.

This information will help us fulfill our grant requirements and let us know who we are serving or not serving in our community. We consider this information private and it will only be reported as part of an aggregate data report.

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* 1. Are You: (Please Choose One)

Male

Female

I prefer not to respond

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* 2. What is your age? (Please choose one)

0-4

5-11

12-14

15-17

18-20

21-24

25-44

45-64

65+

I prefer not to respond

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* 3. What race best describes you? (Please choose one)

Black or African American

White

Native Hawaiian/Other Pacific Islander Asian

American Indian/Alaska Native

More than one race

I prefer not to respond

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* 4. Are you Hispanic/Latino? (Please choose one)

Yes

I prefer not to respond

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* 5. Are you: (Please choose one)

A current member of the armed forces

A veteran

I am not a current member or veteran of the military I prefer not to respond

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* 6. Do you have a family member who is in the military or is a veteran? (Please choose one)

Yes

I prefer not to respond

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* 7. Credentials (select all that apply):

Apprentice Addictions Professional

Certified Alcohol & Drug Counselor

Licensed Alcohol & Drug Counselor

Certified Prevention Specialist

Licensed Social Worker

Licensed Mental Health Clinician

Licensed Marriage & Family Therapist

Working toward licensure or certification

Recovery Coach

Other (please specify)

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* 8. Highest Level of Education:

Doctorate

Medical

Master

Bachelor

Associate

High School or GED

Below High School

Other (please specify)

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* 9. This event has increased my knowledge and/or skill.

Strongly Disagree

Disagree

Neither Agree or Disagree

Agree

Strongly Agree

Please Explain: