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Please take a few minutes to complete this survey.  The data you provide is invaluable to the CHEC Coalition and AHM Youth Services.  All information collected will be annonymous.  If you have already completed this survey, please do not take it again.  At the end of the survey you will have an opportunity to be entered into a drawing to win one of four Stop and Shop gift cards for $25.

* 1. How would you describe yourself? (choose the best one for you)

* 2. Do school aged children live with you in your home?

* 3. What school does the child/children who live in your home attend? (select all that apply)

* 4. The community I live in is:

* 5. Based on your knowledge of the community, what are the top mental health and substance abuse concerns you have in your community? (Please select the top 4, with one being of most concern, and 4 being least of your top 4 concerns)

  1 2 3 4
Tobacco
E-Cigarettes/Electronic Nicotine Delivery Systems (ENDS)
Alcohol/Underage Drinking
Marijuana
Prescription Drug Misuse/Abuse
Heroin
Mental Health Concerns including depression, suicide, anxiety

* 6. Where do you prefer to access information about community related news or events?  (Please select your top 5 choices, with 1 being your first choice and 5 being a less frequent source)

  1 2 3 4 5
River East Newspaper
Journal Inquirer
Reminder News
Willimantic Chronicle
School email
School flyers sent home
AHM Youth and Family Services Facebook page
Other Facebook page
Town Hall posted flyers
Library posted flyers
School or town websites
Local establishments (for example restaurants or grocery stores)
School open house/parent night
Other please specify

* 7. What motivates you to attend community forums or workshops?  (please select all that apply):

* 8. If you were to attend a community forum or workshop, which day of the week and time would be best, please select all that apply:

* 9. Would you agree that it should be required for parents/guardians and their teens to attend an orientation that included information on alcohol, other drugs and related behaviors before students begin the school year?

* 10. What topics would you be interested in learning more about at a community forum or workshop related to youth wellness? (Select all that apply)

* 11. How much do you think youth risk harming themselves physically or in other ways when they use marijuana? (Select one answer)

* 12. What do you think is the safest choice regarding underage drinking? (Select one answer)

* 13. Have you heard of the AHM Substance Abuse Prevention Task Force now called the AHM Coalition for Healthy Empowered Community (AHM CHEC)? If yes, please specify where:

* 14. Did you know that there is a youth committee called RALLY (Regional Activities Leading Local Youth)? If yes, please specify where you heard about this committee:

 

The following two questions are in regards to the CHEC Coalition’s anonymous “tipline”, a webpage that enables anyone in the community to complete an online form to inform police of an upcoming or in progress, underage drinking or drug party, with the goal of keeping youth safe.

* 15. Have you heard of this “tipline” webpage?

* 16. Would you use this “tipline” webpage as described above?

To enter into a drawing to win one of four $25 Stop and Shop gift cards please follow instructions below:

1) FOR PRINT/PAPER COPIES OF THE SURVEY: please tear off this portion of the survey paper or note Haley Shoop, CHEC Coalition Coordinator's, e-mail address and send her an e-mail with your name and phone number included with the topic titles "SURVEY GIFT CARD"

2) FOR ONLINE SURVEYS: please  e-mail Haley Shoop, CHEC Coalition Coordinator, via the address/link below.  Please Title the E-mail "SURVEY GIFT CARD" and include your name and phone number.

Haley Shoop, CHEC Coalition Coordinator's e-mail:  HaleyS@ahmyouth.org


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