SCC BHD-Consumer-2017

1. Do you identify as (Select all that apply):

• Parent
• Partner
• Child
• Other Family Member
• Friend
• None of the Above
• Self

2. What is your stakeholder affiliation?

• Community Member
• Government agency, City or County
• Government agency, State
• Community-based organization
• Law Enforcement
• Education agency
• Social service agency
• Veterans or Veterans Organizations
• Provider of mental health services
• Provider of alcohol and other drug services
• Medical or health care organization
• Other - Write In Please enter an 'other' value for this selection.

3. Please indicate your age range:

• Under 16
• 16-24
• 25-59
• 60 and older

4. What is your ethnicity?

• Hispanic/Latino
• Non-Hispanic/Latino

5. What is your race? (Select all that apply):

• White/Caucasian
• African American/Black
• Asian or Pacific Islander
• American Indian/Native Alaskan
• Multi-Race
• Other - Write In Please enter an 'other' value for this selection.

6. In which part of Santa Clara County do you live?

• Campbell
• Cupertino
• Gilroy
• Los Altos
• Milpitas
• Monte Sereno
• Morgan Hill
• Mountain View
• Palo Alto
• San Jose
• Santa Clara
• Saratoga
• Sunnyvale
• Other - Write In Please enter an 'other' value for this selection.

7. Please indicate your gender:

• Female
• Male
• Transmale/Transman
• Transfemale/Transwoman
• Intersex
• Genderqueer
• Prefer not to answer
• Other - Write In Please enter an 'other' value for this selection.

8. Is English you preferred language?

• Yes
• No