Program Evaluation/Needs assessment

Dear friends,

            In an effort to determine how we can best serve the Morris County community, the Community Coalition for a Safe and Healthy Morris is asking residents to complete the enclosed Drug Free Communities Four Core Measures Survey. This Survey was developed by the United States Office of National Drug Control Policy to measure five specific areas surrounding Alcohol, Tobacco, Marijuana, and Prescription Drugs.  The five identified areas are 30-Day Use, Perception of Risk, Youth Perception of Parental Disapproval, Youth Perception of Peer Disapproval and Youth Attitude Toward Peer Use.

            Please note no names or identifying factors are recorded on the Survey to ensure anonymity and respect for privacy; your youth may also elect not to answer certain questions.  After the Questionnaires have been completed, please place their survey in the enclosed self-addressed stamped envelope.  The compiled data from the Survey will help our county assess needs, refine goals and objectives, and measure change regarding current alcohol and drug prevention programs.

            Thank you for your cooperation and support in helping Morris County residents live safe and healthy lives!

            At the conclusion of this survey, we will be randomly selecting four people to win a $25 Amazon gift card. Please note, that you must opt in to entering your email to be put in for the drawing. Emails will remain confidential and will not be distributed to third party entities or used for any promotional reasons aside from picking the winner for the gift cards.


Sincerely,
 
Community Coalition for Safe and Healthy Morris

Sex:

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* 1. Sex:

Age:

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* 2. Age:

During the past 30 days, did you drink one or more alcoholic beverages? 

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* 3. During the past 30 days, did you drink one or more alcoholic beverages? 

During the past 30 days, did you smoke part or all of a cigarette? 

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* 4. During the past 30 days, did you smoke part or all of a cigarette? 

During the past 30 days have used marijuana, hashish, or some form of THC oil or wax? 

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* 5. During the past 30 days have used marijuana, hashish, or some form of THC oil or wax? 

During the past 30 days have you used prescription drugs NOT prescribed to you? 

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* 6. During the past 30 days have you used prescription drugs NOT prescribed to you? 

Perception of Risk
How much do you think people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week? 

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* 7. How much do you think people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week? 

How much do you think people risk harming themselves physically or in other ways if they smoke one or more packs of cigarettes per day?

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* 8. How much do you think people risk harming themselves physically or in other ways if they smoke one or more packs of cigarettes per day?

How much do you think people risk harming themselves physically or in other ways if they smoke marijuana once or twice a week? 

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* 9. How much do you think people risk harming themselves physically or in other ways if they smoke marijuana once or twice a week? 

How much do you think people risk harming themselves physically or in other ways if they use prescription drugs that are not prescribed to them?

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* 10. How much do you think people risk harming themselves physically or in other ways if they use prescription drugs that are not prescribed to them?

Perception of  Underage Drinking
How wrong do you (if 21+) or your parents (if under 21) feel about someone under 21 drinking one or two alcoholic beverages nearly everyday?  

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* 11. How wrong do you (if 21+) or your parents (if under 21) feel about someone under 21 drinking one or two alcoholic beverages nearly everyday?  

How wrong do you (if 21+) or your parents (if under 21) feel it would be for someone under 21 to smoke tobacco?   

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* 12. How wrong do you (if 21+) or your parents (if under 21) feel it would be for someone under 21 to smoke tobacco?   

How wrong do you or your parents feel for someone underage to smoke marijuana? 

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* 13. How wrong do you or your parents feel for someone underage to smoke marijuana? 

How wrong do you or your parents feel it would be for someone underage to use prescription drugs not prescribed to them?

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* 14. How wrong do you or your parents feel it would be for someone underage to use prescription drugs not prescribed to them?

Perception of Social Disapproval
How wrong do your friends feel it would be for you to have one or two drinks of an alcoholic beverage nearly everyday?

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* 15. How wrong do your friends feel it would be for you to have one or two drinks of an alcoholic beverage nearly everyday?

How wrong do your friends feel it would be for you to smoke tobacco?

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* 16. How wrong do your friends feel it would be for you to smoke tobacco?

How wrong do your friends feel it would be for you to smoke marijuana?

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* 17. How wrong do your friends feel it would be for you to smoke marijuana?

How wrong do your friends feel it would be for you to use prescription drugs not prescribed to you?

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* 18. How wrong do your friends feel it would be for you to use prescription drugs not prescribed to you?

How do you feel about someone your age having one or two alcoholic beverages nearly every day? 

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* 19. How do you feel about someone your age having one or two alcoholic beverages nearly every day? 

Opinion
In your opinion, what do you think the community can be doing to prevent or intervene of underage drinking? 

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* 20. In your opinion, what do you think the community can be doing to prevent or intervene of underage drinking? 

If you would like to be put into the drawing to win a $25 Amazon gift card, please insert your email in the text box. If you do not want to be in the drawing, you may skip this and continue. 

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* 21. If you would like to be put into the drawing to win a $25 Amazon gift card, please insert your email in the text box. If you do not want to be in the drawing, you may skip this and continue. 

Would you like to be kept in the loop with Safe and Healthy Morris? 

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* 22. Would you like to be kept in the loop with Safe and Healthy Morris? 

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