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Natural High Intercept Survey
A survey designed to track public perceptions of and awareness of the Natural High program.
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County:
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Date:
MM
/
DD
/
YYYY
Location/ Event:
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Name:
Your answer
Have you seen the message?
Yes
No
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Do you understand the message?
Yes
No
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Do you agree with the message?
Yes
No
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Gender
Male
Female
Prefer not to say
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Race
White
Black
Asian
Native
Multiple
Other
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Age
5-11
12-14
15-17
18-20
21-24
25-44
45-64
65+
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Was this survey collected at an event that included a Natural High presentation, table or video?
Yes
No
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This form was created inside of Dixie County Anti-Drug Coalition.
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