Community Survey on Prescription Drug Misuse and Abuse

Demographics

Survey respondent demographics.

Question Title

1. What county do you live in? (Required.)

Iredell

Stokes

Surry

Yadkin

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2. Are you male or female? (Required.)

Male

Female

Question Title

3. How old are you? (Required.)

18 – 20

21 – 25

26 – 29

30 – 34

35 – 39

40 – 44

45 – 49

50 – 54

55 – 59

60 – 64

65+

Question Title

4. How would you describe yourself? Check all that apply. (Required.)

White

Black or African American

American Indian or Alaska Native

Asian

Other

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5. Do you consider yourself to be mainly of Spanish, Hispanic, or Latino heritage? (Required.)

Yes

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6. If you answered yes to the question above, what country do you come from?

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7. Are you currently employed either full or part-time? (Required.)

Yes

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8. If you answered no, why are you not currently working either full or part-time?

Caring for children/elderly or stay at home parent/caregiver

Disabled

Student

Retired

Lost or quit job, seeking work

Lost or quit job, not seeking work

No need to work

Question Title

9. Please check any of the places that you have ever worked at or currently work:

Health Department

Pharmacy

Police Department or Sheriff's Office

Any substance abuse treatment facility/agency that provides substance abuse services or counseling

Employed within the Judicial System (JCPC, District Attorney, Lawyer)

Employed by the school system

Hospital Emergency Department (ED) or Emergency Medical Services (EMS)

Other (retail/industry/manufacturing/construction/agriculture/private sector/etc.)

Question Title

10. Are you employed in the medical or dental field with the authority to prescribe medication? (Required.)

Yes

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* 1. What county do you live in? (Required.)

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* 2. Are you male or female? (Required.)

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* 3. How old are you? (Required.)

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* 4. How would you describe yourself? Check all that apply. (Required.)

Question Title

* 5. Do you consider yourself to be mainly of Spanish, Hispanic, or Latino heritage? (Required.)

Question Title

* 6. If you answered yes to the question above, what country do you come from?

Question Title

* 7. Are you currently employed either full or part-time? (Required.)

Question Title

* 8. If you answered no, why are you not currently working either full or part-time?

Question Title

* 9. Please check any of the places that you have ever worked at or currently work:

Question Title

* 10. Are you employed in the medical or dental field with the authority to prescribe medication? (Required.)

1. What county do you live in? (Required.)

2. Are you male or female? (Required.)

3. How old are you? (Required.)

4. How would you describe yourself? Check all that apply. (Required.)

5. Do you consider yourself to be mainly of Spanish, Hispanic, or Latino heritage? (Required.)

6. If you answered yes to the question above, what country do you come from?

7. Are you currently employed either full or part-time? (Required.)

8. If you answered no, why are you not currently working either full or part-time?

9. Please check any of the places that you have ever worked at or currently work:

10. Are you employed in the medical or dental field with the authority to prescribe medication? (Required.)