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* 1. What is your age?

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* 2. What is your gender?

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* 3. What race and/or ethnicity best describes you? (Check all that apply.)

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* 4. What is your highest level of education?

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* 5. What community do you live in?

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* 6. What is your family size?

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* 7. What is your family's annual income?

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* 8. Do you think substance use is a serious problem in your community (this includes alcohol, various street drugs and prescription drugs)?

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* 9. What substances do you feel are the most worrisome in your community? Check your top two answers.

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* 10. What barriers do you believe people face in trying to get help with opioid or substance use? Choose your top two answers.

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* 11. Which of the following services do you feel would be useful in your community? Check your top three choices.

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* 12. Are you currently dependent on opioids or other substances?

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