Community Perceptions Survey
Mark the response that you feel best fits the question.  Your individual responses will be kept anonymous.
 
Check the box for your age group:
17 or younger
18-25
26 -40
41 - 59
60 and older
THE FOLLOWING SECTION IS RELATED TO ALCOHOL USE.
 
For items 1-7, please indicate what you think others believe about alcohol use. 
 Strongly agree Agree Disagree Strongly disagree Don't know 
1. Most adults in my community think that binge drinking by other adults is acceptable. (Binge drinking is defined as having five or more drinks in a single session.)
2. Most adults in my community think that binge drinking by people age 18 to 20 is acceptable.
3. Most adults in my community think that binge drinking by people under age 18 is acceptable.
4. Most adults in my community think that it is OK to drink alcohol and drive.
5. Most adults in my community think that it is OK if they drink and drive, as long as they haven't had too many alcoholic drinks.
6. Most adults in my community think that it is OK for people age 18 to 20 to drink alcohol.
7. Most adults in my community think that it is OK for people under age 18 to drink alcohol.
For items 8-33, indicate what you believe about alcohol use.
 
How difficult do you think it is for youth in our community to obtain alcohol from:
 Very Difficult Somewhat Difficult Not Difficult at All   
8. Older siblings?   
9. Parents?   
10. Other adult relatives?   
11. Same-age friends?   
12. Adult strangers?   
13. Bars?   
14. Restaurants?   
15. Liquor stores?   
16. Grocery stores?   
17. Convenience stores?   
18. How difficult do you think it is for youth to get alcohol from home without their parents' knowledge?
Very Difficult
Somewhat Difficult
Not Difficult at All
How difficult do you think it is for people aged 18-20 in our community to obtain alcohol from:
 Very Difficult Somewhat Difficult Not Difficult at All   
19. Older siblings?   
20. Parents?   
21. Other adult relatives?   
22. Same-age friends?   
23. Friends aged 21 or older?   
24. Adult strangers?   
25. Bars?   
26. Restaurants?   
27. Liquor stores?   
28. Convenience/Grocery Stores?   
29.  About what percentage of parents in our community do you think have provided alcohol for other people's children in their own homes?
 

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30. About what percentage of parents in our community do you think have allowed other people's children to drink alcohol in their homes?   
 

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31.  About what percentage of parents in our community do you think do not pay enough attention to whether other people's children are drinking alcohol in their homes?
 

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32.  Do you believe that alcohol is a problem in our community?

Yes
No
33.  If you answered yes to question 32, please list some reasons that you think alcohol is a problem in our community.
 

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THE FOLLOWING SECTION IS RELATED TO PRESCRIPTION DRUG ABUSE.
 

For items 34-36, please indicate what you think others believe about prescription drug abuse.

 Strongly agree Agree Disagree Strongly disagree Don't know 
34. Most people in my community think that sharing their own prescription medications with others is okay.
35. Most people in my community think that using medications not prescribed to them is okay.
36. Most people in my community think that using their own prescription medications in ways not instructed by a doctor is okay. (For example, taking more than prescribed or more often than prescribed.)

For items 37-43, please indicate what you believe about prescription drug abuse.

 Strongly agree Agree Disagree Strongly disagree Don't know 
37. Medication theft is a problem in my community.
38. Prescription drug abuse is a problem in my community.
39. My community is doing enough to combat prescription drug abuse.
40. There is enough information available in my community about prescription drug abuse.

41. If you answered "strongly agree" or "agree" to number 38 (Prescription drug abuse is a problem in my community), please list some reasons that you think prescription drug abuse is a problem in our community. 

 

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42.  How difficult do you think it is for people in our community to obtain prescription medications for misuse? (choose one)

Very difficult
Somewhat difficult
Not difficult at all
Don't know
43.  How do you think people in our community most often obtain prescription medications for misuse? (choose up to 3)
Given by family members
Given by friends
Purchased from someone they know
Purchased online
Taken from family members (at home)
Taken from someone they know (outside of the home)
Stolen from strangers
Obtained from doctors by providing false information
THE FOLLOWING SECTION IS RELATED TO ILLEGAL DRUG USE.
 
For items 44-47, please indicate what you believe about illegal drug use.
 Strongly agree Agree Disagree Strongly disagree Don't know 
44. In my community, illegal drugs are easy to obtain.
45. Illegal drug use is a problem in my community.
46. My community is doing enough to combat illegal drug use.
47. In my community, there is enough information available about illegal drug use.

48. If you answered "strongly agree" or "agree" to number 38 (prescription drug abuse is a problem in my community) and/or number 44 (illegal drugs are easy to obtain) , please indicate which drugs you believe are most commonly found in our community (mark all that apply):

Adderall
Benzodiazapines
Cocaine
Crack Cocaine
Fentanyl
Heroin
Marijuana
MDMA Ecstacy
Meth
Methadone
Spice/Synthetic Marijuana
Steroids
Suboxone
Other  
49.  If you answered "strongly agree" or "agree" to number 45 (Illegal drug use is a problem in my community), please list some reasons that you think illegal drug use is a problem in our community.
 

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50.  Mark any of the following that you would like to see in our community. 

More frequent medication collection events
Permanent medication drop-off sites
Online networking and information websites for obtaining information about substance use and abuse
Information shared at doctor's offices/pharmacies about prescription drug safety/storge/disposa-
l
Opportunities for drug safety presentations. Where? (record location in comments section)
Youth prevention/education in schools and youth serving organizations
Other  
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Thank you for taking the time to complete this survey. Your participation is greatly appreciated. If you have additional comments that you'd like to provide, you may do so in the section below.  

 

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