Your Voice Matters Tell us what things you believe are affecting the health and safety of the youth in the Elizabethtown community. You can help make a difference in our community by completing the following SHORT survey. Question Title * 1. Do you live in the Elizabethtown Area School District? Yes No Question Title * 2. Which category below includes your age? 20-30 31-40 41-50 51-60 60-70 71+ Question Title * 3. Do you currently have or are you caring for a school-aged child(ren) in your home? Yes No Question Title * 4. In our community, to what extent are the following issues a problem for our youth? No Problem Problem Serious Problem Alcohol Use Alcohol Use No Problem Alcohol Use Problem Alcohol Use Serious Problem Marijuana Use Marijuana Use No Problem Marijuana Use Problem Marijuana Use Serious Problem Heroin Use Heroin Use No Problem Heroin Use Problem Heroin Use Serious Problem Prescription drug use for nonprescription reasons Prescription drug use for nonprescription reasons No Problem Prescription drug use for nonprescription reasons Problem Prescription drug use for nonprescription reasons Serious Problem Driving under the influence of alcohol or drugs Driving under the influence of alcohol or drugs No Problem Driving under the influence of alcohol or drugs Problem Driving under the influence of alcohol or drugs Serious Problem Question Title * 5. To what extent, do you feel we can have an impact on our youth's involvement with the following? We can stop it. It can be reduced. We have no control over it. Alcohol Use Alcohol Use We can stop it. Alcohol Use It can be reduced. Alcohol Use We have no control over it. Marijuana Use Marijuana Use We can stop it. Marijuana Use It can be reduced. Marijuana Use We have no control over it. Heroin Use Heroin Use We can stop it. Heroin Use It can be reduced. Heroin Use We have no control over it. Prescription drug use for nonprescription reasons Prescription drug use for nonprescription reasons We can stop it. Prescription drug use for nonprescription reasons It can be reduced. Prescription drug use for nonprescription reasons We have no control over it. Driving under the influence of alcohol or drugs Driving under the influence of alcohol or drugs We can stop it. Driving under the influence of alcohol or drugs It can be reduced. Driving under the influence of alcohol or drugs We have no control over it. Question Title * 6. Who do you believe is the MOST responsible for addressing the issues below? (Select one per issue) Community School Police Family Healthcare Church Alcohol Use Alcohol Use Community Alcohol Use School Alcohol Use Police Alcohol Use Family Alcohol Use Healthcare Alcohol Use Church Marijuana Use Marijuana Use Community Marijuana Use School Marijuana Use Police Marijuana Use Family Marijuana Use Healthcare Marijuana Use Church Heroin Use Heroin Use Community Heroin Use School Heroin Use Police Heroin Use Family Heroin Use Healthcare Heroin Use Church Prescription drug use for nonprescription reasons Prescription drug use for nonprescription reasons Community Prescription drug use for nonprescription reasons School Prescription drug use for nonprescription reasons Police Prescription drug use for nonprescription reasons Family Prescription drug use for nonprescription reasons Healthcare Prescription drug use for nonprescription reasons Church Driving under the influence of alcohol or drugs Driving under the influence of alcohol or drugs Community Driving under the influence of alcohol or drugs School Driving under the influence of alcohol or drugs Police Driving under the influence of alcohol or drugs Family Driving under the influence of alcohol or drugs Healthcare Driving under the influence of alcohol or drugs Church Other (please specify who is responsible and for which issue.) Question Title * 7. How do you believe MOST underage drinkers get their alcohol (Choose all that apply) A parent gave it to them They took it from a parent without permission From another relative From a friend over 21 years old From a friend under 21 years old From a stranger Bought it at a store (distributor or State Store) Bought it at a restaurant or bar Stole it from a store/restaurant/bar Other (please specify) Question Title * 8. Do you believe people in our community are willing to get involved in addressing the following youth concerns? Not Willing Somewhat Willing Very Willing Alcohol Use Alcohol Use Not Willing Alcohol Use Somewhat Willing Alcohol Use Very Willing Marijuana Use Marijuana Use Not Willing Marijuana Use Somewhat Willing Marijuana Use Very Willing Heroin Use Heroin Use Not Willing Heroin Use Somewhat Willing Heroin Use Very Willing Prescription drug use for nonprescription reasons Prescription drug use for nonprescription reasons Not Willing Prescription drug use for nonprescription reasons Somewhat Willing Prescription drug use for nonprescription reasons Very Willing Driving under the influence of alcohol or drugs Driving under the influence of alcohol or drugs Not Willing Driving under the influence of alcohol or drugs Somewhat Willing Driving under the influence of alcohol or drugs Very Willing Question Title * 9. What are some things you would like to see happen that will get you or others involved in addressing the above concerns affecting our youth and community? Question Title * 10. If interested in helping our community address these issues, please share your contact information: Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Done
