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PAX Tools Interest Survey
1.
Name
First Name
Last Name
2.
Email Address
3.
Phone Number
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
5.
Agency/Entity
6.
Type of Agency/Entity
Education/School
Behavioral Health/ Prevention Provider
Medical/Public Health
Community Coalition
Other- Please Specify
7.
Agency/Entity Phone Number
8.
Agency/Entity City
9.
Agency/Entity County
10.
Please describe the community you serve.
11.
Approximately how many families do you plan to share these resources with?
1-49
50-99
100-149
150-199
200+
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
13.
What age range are the children in the homes you would be targeting?
0-4
5-9
10-14
15 and up
Current Progress,
0 of 14 answered