Check the social/occupational sector you represent.

	Clergy
	Education
	Legal
	Medical
	Public Official
	Social Service Provider
	Other

Do you consider alcohol to be a problem in your community?

	Yes
	No

If yes, is it a _____________ problem?  Check all that apply.

	Criminal
	Driving
	Health
	Moral
	Nutritional
	Violence
	Other

Is underage drinking a problem in your community?

	Yes
	No

If yes, is it a _____________ problem? Check all that apply

	Criminal
	Driving
	Health
	Moral
	Nutritional
	Violence
	Other

Alcohol is easily accessible to minors in this community.

	Strongly Agree
	Agree
	Don't Know
	Disagree
	Strongly Disagree

Check the items from the list that contribute to underage drinking.

	Parents
	Other adults
	Liquor stores
	Teen boredom
	Peer pressure
	Depression
	Entertainment
	Everyone does it
	Lack of law enforcement
	Advertising
	Lack of Education
	Acceptance by Society

What resources are available in your community to address alcohol use among minors?

	Community based prevention programs
	Law enforcement
	School based prevention programs
	Parent groups
	Alcohol server/seller training
	Student/youth groups
	Other (specify)

What agencies do you think should be involved in dealing with underage drinking?

	Youth Service agencies
	Police departments
	Human and health service agencies
	Courts
	School Systems
	Faith based
	Other (specify)

Select the solutions you favor to reduce underage drinking.

	Tag beer kegs with the id of purchaser
	800 number for citizens to report stores that sell to minors
	Server/seller training programs for places that sell alcohol
	A public awareness campaign
	Mandatory sentencing for sellers to minors
	Suspend drivers licenses of underage drinkers
	Prosecute parents/adults who provide alcohol to minors
	Lower legal drinking age
	Raise legal drinking age
	Other (specify)

Does your organization provide, sponsor, or provide space for any alcohol/drug related services?

	Yes
	No

If yes, which best describes your services?

	Prevention
	Treatment
	Education
	Recovery (AA/NA meetings)
	Intervention
	Other
	If your alcohol service has a name, what is it?