PAX Tools Interest Survey Question Title * 1. Name First Name Last Name OK Question Title * 2. Email Address OK Question Title * 3. Phone Number OK Question Title * 4. What is your professional role? Prevention Education/Awareness Mental Health and Recovery Community Health Education Faith-Based Volunteer County Health Dept. Alcohol, Drug Addiction and Mental Health Services Extension Office OK Question Title * 5. Agency/Entity OK Question Title * 6. Type of Agency/Entity Education/School Behavioral Health/ Prevention Provider Medical/Public Health Community Coalition Other- Please Specify OK Question Title * 7. Agency/Entity Phone Number OK Question Title * 8. Agency/Entity City OK Question Title * 9. Agency/Entity County OK Question Title * 10. Please describe the community you serve. OK Question Title * 11. Approximately how many families do you plan to share these resources with? 1-49 50-99 100-149 150-199 200+ OK Question Title * 12. Approximately how many children could be impacted by sharing these resources with those families? Fewer than 100 100-500 500-1000 More than 1000 OK Question Title * 13. What age range are the children in the homes you would be targeting? 0-4 5-9 10-14 15 and up OK NEXT