Community Survey

This voluntary survey will take less than five minutes to complete. Your responses will help guide us in building a healthy community.

Participant Information

We are required by the NJ Department Human Services and the U.S Department of Health and Human Services to collect the following data. We would appreciate your cooperation in completing the following

Age 18 - 20 21 - 24 25 - 44 45 - 64 65+

Race/Ethnicity: Please Select Caucasian Black - African American Latino / Hispanic Asian Native American Other

Gender Male Female Transgender

I live in

My County

Community Survey

It is okay for parents and other adults to allow underage drinking in their home. Agree/Yes Disagree/No

It is okay to allow underage drinking in private homes as long as it is in a controlled setting (e.g. car keys are collected, designated drivers are assigned) Agree/Yes Disagree/No

I am aware of neighbors or other adults who allow underage drinking in their home. Agree/Yes Disagree/No

I allow underage drinking in my home. Agree/Yes Disagree/No

I monitor the amount of alcohol in my home on a regular basis. Agree/Yes Disagree/No

I believe that alcohol laws/regulations (e.g. carding for 21 at retail stores and bars) are enforced regularly in my community. Agree/Yes Disagree/No

I believe that alcohol is bad for an adolescent’s brain. Agree/Yes Disagree/No

I am aware of youth who use prescription drugs without a prescription. Agree/Yes Disagree/No

The proper way to dispose of prescription and/or over-the-counter drugs is by flushing them down the toilet. Agree/Yes Disagree/No

I monitor and secure the medications in my home. Agree/Yes Disagree/No

It is okay to take someone else’s prescription drug. Agree/Yes Disagree/No

Prescription drugs can be just as dangerous as street drugs. Agree/Yes Disagree/No

I know where to get information on alcohol, tobacco, and other drugs. Agree/Yes Disagree/No

If there was a local place to discard expired or unused medications at no cost, I would regularly use this service. Agree/Yes Disagree/No

Are you a parent, grandparent, or a guardian providing a home for a child/children under age 21 Yes No

My family has dinner together regularly. Agree/Yes Disagree/No

My underage (under 21) child(ren) drink(s) alcohol on a regular basis. Agree/Yes Disagree/No

I talk with my child(ren) about alcohol, drugs, and tobacco on a regular basis (at least three times per year). Agree/Yes Disagree/No

I have clear and specific rules about my child(ren)’s association with peers who use alcohol and/or drugs. Agree/Yes Disagree/No

I have children of the following ages (check all that apply) 0-4 5-11 12-14 15-17 18-20

Please check you have answered all the questions and then click the submit button so your results will be added to our survey.

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THANK YOU!

Your completed surveys to: will be processed by

Coalition for Healthy Communities

620 Cranbury Road, Suite 105,

East Brunswick, NJ 08816