Tylers Light November 2017 Survey
100%
Questions marked with a
*
are required
Exit Survey
*
Have you ever used an opioid medication to get high?
Yes
No
Uncertain
*
Have you or a member of your immediate family (father, mother, brother, sister) been prescribed an opioid medication during the past twelve months?
Yes
No
Uncertain
*
Do you know someone who is using opioid medication to get high?
Yes
No
Uncertain
*
Do you know someone who is using heroin or fentanyl to get high?
Yes
No
Uncertain
*
Do you know anyone who has died from an overdose?
Yes
No
Uncertain
*
Have you considered using either opioid medication or heroin to get high?
Yes
No
Uncertain
*
After today’s presentation:
I am less likely to use opioid medication or heroin to get high.
I am more likely to use opioid medication or heroin to get high.
My intention to use is the same.
*
What did you like best about today’s presentation?
*
What did you like least about today’s presentation?
*
What was missing from today’s presentation?
*
What grade are you in?
-- Select --
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College
*
What is your gender?
Male
Female
*
What is your ethnicity?
-- Select --
White
Black or African American
Asian / Pacific Islander
Hispanic or Latino
Native American or American Indian
Other
*
May we contact you via email to provide information about our upcoming events? We value your input and promise that ALL information is strictly confidential and will not be shared.
Yes
No
Thank you for allowing us to contact you. Please provide your email address . You can unsubscribe at any time.
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