Please fill out the survey to the best of your ability.
All information will remain confidential.
Please answer all questions.

For each of the following, please circle the number that indicates the degree to which you think these issues are a problem in your community, with "1" meaning "very much a problem" and "7" meaning "not at all a problem".

	Very Much                                                                                       Not at All
1. Child abuse	1        2        3        4        5        6        7
2. Youth violence	1        2        3        4        5        6        7
3. Lack of recreational youth activities	1        2        3        4        5        6        7
4. Access to health care	1        2        3        4        5        6        7
5. Mental health problems	1        2        3        4        5        6        7
6. HIV/AIDS	1        2        3        4        5        6        7
7. Homelessness	1        2        3        4        5        6        7
8. Poverty	1        2        3        4        5        6        7
9. Alcohol related problems (ie. marital problems, absenteeism from work, etc.)	1        2        3        4        5        6        7
10. Crime	1        2        3        4        5        6        7
11. Illegal drug use	1        2        3        4        5        6        7
12. Domestic violence	1        2        3        4        5        6        7
13. Unemployment	1        2        3        4        5        6        7
14. Racism	1        2        3        4        5        6        7

15. Are you aware of any drug prevention programs at local schools or at your workplace?        

Schools:	Yes        No        Not Sure
Workplace:	Yes        No        Not Sure

16. Would you like to see more alcohol, tobacco and other drug prevention programs in your area?      
Yes        No        Not Sure        

17. If you needed or wanted information on alcohol, tobacco and other drug facts and issues, would you know where to go?      
Yes        No        Not Sure        

18. Would you allow underage youth to drink in your home?      
Yes        No        Not Sure        

19. Would you allow underage youth to smoke in your home?      
Yes        No        Not Sure        

20. What is your age?      
7-12        13-18        19-64        65-79        80+        

21. Which best describes your racial ethnic origin (you may check more than one)?
CaucasianAfrican AmericanHispanicAsianNative AmericanOther

22. How many people are living in your household?           


23. What is your marital status?      
Single      Married      Divorced/Separated      Widowed      Single/Cohabit      

24. What is the highest grade you completed?      
Less than 6thSome College
7thAA
8thBA/BS
9thSome Graduate
10thMaster's Degree
11thPHD/MD/JD
High School or GED

25. Annual household income:      
Less than $10,000
$10,000-20,000
$21,000-35,000
$36,000-50,000
$51,000-75,000
$76,000-100,000
$100,000+

26. County of residence: