default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. Date: Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2187-12-31 23:59:59.999 MM-DD-YYYY Community Health Advocate? Choose one of the following answers Yes No No answer Other: Trainer Neighborhood/Town Training Site: Choose one of the following answers If you choose 'Other:' please also specify your choice in the accompanying text field. East Liberty Hill Perry Hilltop Overbrook PPP Office Homewood Other: No answer (This question is mandatory) Is this a refill or an initial training? Choose one of the following answers Refill Initial training Other: Gender: Choose one of the following answers Male Female Transgender No answer Race / ethnicity: Choose one of the following answers White Black Latinx Asian Native Multiracial Other: No answer Year of birth: Only numbers may be entered in this field. Have you used any drugs or alcohol in the last 30 days? Choose one of the following answers Yes No No answer Other: Check which drugs or meds you have used in the last 30 days Sometimes Daily No answer Heroin Sometimes Daily No answer Fentanyl (powder) Sometimes Daily No answer Methadone Sometimes Daily No answer Opioid Pain Meds: (Morphine, Percocet, Oxycodone, Opana (Oxymorphone), Roxicodone, Vicodin, Codeine, Dilaudid, Fentanyl patch) Sometimes Daily No answer Buprenorphine (Suboxone, Subutex, Zubsolv) Sometimes Daily No answer Benzos: (Klonopin, Xanax, Ativan, Valium, Librium) Sometimes Daily No answer Cocaine or Crack Sometimes Daily No answer Alcohol Sometimes Daily No answer Methamphetamine Sometimes Daily No answer Amphetamines: Ritalin, Concerta, Adderall Sometimes Daily No answer K-2 Sometimes Daily No answer Declined to Answer Sometimes Daily No answer Next Please confirm you want to clear your response? Exit and clear survey
