Baseline Survey of the Community

The following survey will help the Lackawanna Opioid Coalition understand the type and amount of stigma currently residing in the attitudes and behaviors of members in our community.  Your answers from this survey will be kept confidential and will only be reported as a group.  The answers will indicate the type of training and education that will best reduce present stigma relating to opioid use disorder and overdoses amongst the community

Demographics

Question Title

* 1. Please indicate the date of survey:

Date / Time

Question Title

* 2. Please indicate your age:

Question Title

* 3. Please indicate your gender:

Question Title

* 4. Please indicate your race:

Question Title

* 5. Please indicate your highest completed level of education:

Question Title

* 6. Please indicate if you currently have or previously had a substance use disorder:

Question Title

* 7. Please indicate if someone you know currently has or previously had a substance use disorder:

Question Title

* 8. Please indicate your occupation:

Question Title

* 9. Please indicate your zip code of residence:

T