Community Action Network:  Think Smart Oklahoma

In an effort to reduce opioid deaths, the Cherokee Nation, as part of  Strategic Prevention Framework projects, is providing medication safes at no cost to 1,000 households in Northeast Oklahoma.  To evaluate the impact of this pilot project, we need you to complete this HIPAA compliant survey when you receive the safe and then complete a follow-up survey in three months.  The surveys will take less than five minutes to complete.  You will be reminded to take the follow-up survey at least one week before the deadline.  Your information will be aggregated in the report and your contact information will be stored only for your follow-up survey reminder. 

* 1. I understand that by accepting the medication safe, that I am agreeing to participate in this pilot project.  As part of the project, I will complete the necessary surveys for the prevention specialists to track outcomes.

* 2. What is your gender?

* 3. Please check your ethnicity.

* 4. What is your age?

* 5. What county provided your medication safe?

* 6. When did you receive your medication safe?

* 7. How do you want to receive your follow-up survey notification?

* 8. Please provide information based on your notification preference.  Leave choices blank if they are not applicable.

* 9. Where did you keep your medications before receiving your safe?

* 10. Please check all true statements for your household.

* 11. If you are having issues with the medication safe, please describe them.

* 12. Please share other comments about opioid misuse.

* 13. Do you want a prevention specialist to contact you regarding your comments or concerns? (We will use your preferred notification method.)

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