Local Community Needs Assessment Survey

Instructions

The Jefferson County Department of Health wants to measure the community’s awareness and use of drug overdose prevention and treatment resources. Please take 5 minutes to complete the survey to give us your feedback. Your answers are anonymous and will be used to help guide our efforts on increasing access to overdose prevention resources.

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* 1. How do you describe your gender?

Male

Female

Non-Binary

Male to Female Transgender

Female to Male Transgender

Other (please specify)

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* 2. What is your age?

18 or under

19-24

25-34

35-44

45-54

55-64

65-74

75 or older

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* 3. With which race or ethnicity do you primarily identify?

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latinx

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Prefer not to answer

More than One Race or Other (please specify)