Survey & Form Center

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6. Important

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10. General Information
12. Organization's Name*
14. Organization Type*
    -- Select One --COMBAT-Funded Program ProviderLaw EnforcementLocal GovernmentOther
16. COMBAT-Funded Program Type*

    Check All That Apply

    1. Substance Abuse Prevention
    2. Violence Prevention
    3. Treatment
    4. Law Enforcement School-Based
    5. STRIVIN' Hub
18. You Chose "Other." Please Specify.*
20. Workshop Participants

    Limit two per organization

22. Name*
23. Title*
25. Phone*
26. e-mail*
30. Name
31. Title
33. Phone
34. e-mail

36. e-mail updates will be sent to the addresses listed above

40. Dietary Restrictions?*

    Does anyone attending this event from your organization have dietary restrictions (allergies, gluten intolerance, etc.) that we need to be aware of?

    1. Yes
    2. No
42. Please Specific Dietary Restrictions*
44. Discussion Topics

    Help us select the topics of discussion for the symposium.

46. Fentanyl*

    How do we raise awareness, andwhat messaging can help reduce overdoses?

    1. 5 - Most Important
    2. 4 - Very Important
    3. 3 - Important
    4. 2 - Somewhat Important
    5. 1 - Not As Important As Other Topics
48. School Violence*

    What are the challenges facing schools in the wake of pandemic?

    1. 5 - Most Important
    2. 4 - Very Important
    3. 3 - Important
    4. 2 - Somewhat Important
    5. 1 - Not As Important As Other Topics
50. Gun Violence*

    What actions can we take to reduce the number of firearm fatalties and injuries in our community?

    1. 5 - Most Important
    2. 4 - Very Important
    3. 3 - Important
    4. 2 - Somewhat Important
    5. 1 - Not As Important As Other Topics
52. Legal Marijuana*

    What challengs does legalized marijuana use pose, including increased violence associated with the ongoing illegal sale of marijuana?

    1. 5 - Most Important
    2. 4 - Very Important
    3. 3 - Important
    4. 2 - Somewhat Important
    5. 1 - Not As Important As Other Topics
54. Other

    Is there another topic you think we should discuss besides those suggested above?

    1. Yes
    2. No
56. Other Topic*

    Please specific the other topic of discussion and any questions we should try to address regarding that topic.

58. Other Topic*

    1. 5 - Most Important
    2. 4 - Very Important
    3. 3 - Important
    4. 2 - Somewhat Important
    5. 1 - Not As Important As Other Topics
60. Signature

62. By typing your name in the "Signature" box below, you acknowledge that this "electronic signature" is valid to the same effect of a traditional handwritten signature.

64. Signature*
65. Date*
    Date
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67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field