Instructions

This form examines your opinions and thoughts about addictive substances such as alcohol, cocaine, marijuana, tobacco, and opioids.  Examples of opioids include heroin, fentanyl, oxycodone, hydrocodone, codeine, morphine.  Street names include “Hydro, Oxy, Norco, Vikes, Demmies, and Percs.”  Opioids are sometimes prescribed by a doctor for medical treatment.  Signs of addiction include using opioids to get high or feeling as if you need to use the drug even when its use is harming you or others.  

The information you provide will help us understand the value of these types of events and what changes may be helpful to better achieve meeting objectives. 

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* 1. What are your first and last name initials?

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* 2. What is your birthdate?

Date

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* 3. What zip code do you live in?

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* 4. Learning information about opioids is important to me.

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* 5. Learning new skills to address issues related to substance use disorder (addiction to substances such as alcohol, marijuana, cocaine and opioids) is helpful.

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* 6. Reducing false beliefs about substance use disorder (addiction to substances such as alcohol, marijuana, cocaine and opioids) improve access to recovery. [National Institute of Drug Abuse definition of recovery:  A process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential.]

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* 7. A house of worship is a good place to seek help for addiction to any drug.

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* 8. People struggling with opioid use disorder (addiction to opioids) cannot be helped by this house of worship.

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* 9.  I am reluctant to assist people struggling with opioid use disorder (addiction to opioids).

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* 10. I am reluctant to assist people struggling with substance use disorder (addiction to substances such as alcohol, marijuana, cocaine and opioids).

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* 11. I know how to assist someone experiencing an opioid overdose.

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* 12. I have information on treatment resources for substance use disorder (addiction to substances such as alcohol, marijuana, cocaine and opioids) that I can share with individuals who need them.

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* 13. I am knowledgeable of the signs and symptoms of substance use disorder (addiction to substances such as alcohol, marijuana, cocaine and opioids).

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* 14. I am knowledgeable of the signs and symptoms of opioid use disorder (addiction to opioids).

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* 15. The speaker(s) provided me with information I can use on how to address all addictive substances such as opioids, alcohol, tobacco, and other drugs.

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* 16. The virtual format of this event allowed me to stay engaged.

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* 17. I will use the knowledge that I received during this event to help others impacted by the opioid crisis.

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* 18. I would return to this house of worship to learn more about how to address substance use disorders (e.g., addiction to opioids, marijuana, cocaine, alcohol, and other substances).

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* 19. Please describe how the organizers can improve their work:

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* 20. What did you like most about this event?

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