Opioid health disparities-Siskiyou-Prescribing to Prevention-2019 Survey

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* 1. Do you live in Siskiyou County?

Yes

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* 2. If no, what county do you live in?

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* 3. What City do you live in?

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* 4. What is your AGE?

0-4

5-11

12-14

15-17

18-20

21-24

25-44

45-64

65-Over

NO ANSWER

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* 5. ETHNICITY: Are you HISPANIC or LATINO?

Yes

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* 6. RACE:

WHITE

BLACK

NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER

ASIAN

NATIVE INDIAN/ALASKA NATIVE

MORE THAN ONE RACE

RACE UNKNOWN

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* 7. GENDER: How do you identify?

MALE

FEMALE

OTHER

Choose not to answer

OTHER: How do you identify?

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* 8. Have you ever been diagnosed with any type of Mental Disorder?

Yes

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* 9. Have you ever misused or abused prescription OPIOIDS?

Yes

Maybe

I am not sure what Opioids are

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* 10. Have you ever used illicit OPIOIDS (such as Heroin-Fentanyl-Opium)?

Yes

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* 11. Do you currently misuse or abuse prescription OPIOIDS?

Yes

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* 12. Do you currently use illicit OPIOIDS (such as Heroin-Fentanyl-Opium)?

Yes

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* 13. Have you ever been prescribed OPIOIDS following an injury?

Yes

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* 14. Have you ever been prescribed OPIOIDS following a dentist visit?

Yes

Other reason for being prescribed Opioids

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* 15. Do you keep unused prescription Opioids for future use?

Yes

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* 16. If you have in the past or are currently abusing/misusing OPIOIDS, do you believe it started with prescription OPIOIDS?

Yes

This does not apply to me

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* 17. Did you ever transition from prescription OPIOIDS to illicit OPIOIDS?

Yes

Never misused or abused OPIOIDS

This does not apply to me

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* 18. Have you ever shared a prescription OPIOID with someone else?

Yes

Not Sure

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* 19. Has anyone ever shared a prescription OPIOID with you?

Yes

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* 20. Do you know where to dispose of unused prescription Opioids in Siskiyou County?

Yes

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* 21. Have you ever taken someone else's OPIOID prescription without their knowledge?

Yes

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* 22. Have you ever committed a crime to attain / acquire or purchase OPIOIDS?

Yes

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* 23. Have you ever sold OPIOIDS (unused prescription or illicit) to another person?

Yes

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* 24. If you are abusing or misusing OPIOIDS, have you considered treatment?

Yes

I am currently in treatment

I have had treatment and I am in recovery

This does not apply to me

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* 25. If you are abusing or misusing OPIOIDS, do you have access to treatment?

Yes

This does not apply to me

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* 26. If you feel you do not have access to treatment, can you briefly describe why?

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* 27. What is your employment status?

Employed-Full TIme

Employed-Part Time

Unemployed

Going to School

Homemaker

Retired

Receiving/Awaiting approval for disability payments

OTHER please describe

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* 28. Are you considered low income?

Yes

I am not sure

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* 29. Are you in poverty?

Yes

I am not sure

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* 30. Are you homeless?

Yes

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* 31. If you are homeless, do you believe OPIOID misuse or abuse is or was a contributing factor?

Yes

This question does not apply to me

I am homeless for another reason (please describe)

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* 32. Do you live in a remote location?

Yes

I am not sure

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* 33. If you do live in a remote location, does this impact your access to health care or treatment?

Yes

Does not apply to me

My remote location impacts my access because (Please Describe)