Pitt County Forms Center

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   1717 W. 5th Street Greenville, NC 27834  |  Telephone: (252) 902-1000

   Survey of Community Organizations for the Opioid Settlement
    

4. First Name:*
5. Last Name:*
7. Program/Organization's Name:*
9. Program/Organization's Zip Code:*
10. Program/Organization's Age (In Years):*
    -- Select One --<55-1011-1516-20>20
12. What cause led to the start of your program/organization? (select all that apply)*

    1. Death of friend or family member
    2. Personal experience with drug use
    3. Health Care Professional
    4. Advocate/Activist

    1. Court/Legal system
    2. Treatment/recovery costs
    3. Lack of accessing to treatment
    4. Other (Please Explain)
14. If "Other" was selected for the above question, please explain here:*
16. Which of the following describes your personal and/or professional involvement in the opioid crisis? (select all that apply)*

    1. Person in recovery from opioid use
    2. Family member of a person uses/used opioids
    3. Medical healthcare provider
    4. Behavioral healthcare provider
    5. Emergency medical services (EMS/Fire)
    6. Public Health
    7. Law Enforcement/ Public Safety
    8. Housing/ Residential Placement
    9. Child-serving Organization

    1. Judicial System
    2. Harm Reduction
    3. Substance use prevention
    4. Recovery and /or Peer Support
    5. Government Agency
    6. Volunteer Organizations
    7. Faith Based Organization
    8. Educator
    9. Other (Please Explain)
18. If "Other" was selected for the above question, please explain here:*
20. There are 12 pre-approved evidence-based strategies our Opioid Settlement Funding can be spent on. Please select the top 3 strategies you would like to see the funding spent on.*

    1. Collaborative strategic planning: Support planning to address opioid misuse, addiction, overdose, or related issues, including staff support, facilitation services, etc.
    2. Evidence-based addiction treatment: Support evidence-based addiction treatment consistent with the American Society of Addiction Medicine’s national practice guidelines for the treatment of opioid use disorder.
    3. Recovery support services: Fund evidence-based recovery support services, including peer support specialists or care navigators based in local health departments, social service offices, detention facilities, community-based organizations, etc.
    4. Recovery housing support: Fund programs offering recovery housing support to people in treatment or recovery, or people who use drugs, such as assistance with rent, move-in deposits, or utilities.
    5. Employment-related services: Fund programs offering employment support services to people in treatment or recovery, or people who use drugs, such as job training, job skills, job placement, interview coaching, resume review, professional attire, relevant courses at community colleges or vocational schools, etc.
    6. Early intervention: Fund programs, services, or training to encourage early identification and intervention for children or adolescents who may be struggling with problematic use of drugs or mental health conditions.
    7. Naloxone distribution: Support programs or organizations that distribute naloxone (the overdose reversal medication, also known as Narcan) to persons at risk of overdose or their social networks, such as Syringe Service Programs, post-overdose response teams, programs that provide naloxone to persons upon release from jail or prison, emergency medical service providers or hospital emergency departments that provide naloxone to persons at risk of overdose, etc.
    8. Post-overdose response team: Support post-overdose response teams that connect persons who have experienced non-fatal drug overdoses to addiction treatment, recovery support, harm reduction services, primary healthcare, or other services or supports they need to improve their health or well-being.
    9. Syringe Service Program: Support Syringe Service Programs operated by any governmental or nongovernmental organization authorized by section 90-113.27 of the North Carolina General Statutes that provide syringes, naloxone, or other harm reduction supplies; that dispose of used syringes; that connect clients to prevention, treatment, recovery support, behavioral healthcare, primary healthcare, or other services or supports they need.
    10. Criminal justice diversion programs: Support pre-arrest or post-arrest diversion programs, or pre-trial service programs, that connect individuals involved or at risk of becoming involved in the criminal justice system to addiction treatment, recovery support, harm reduction services, primary healthcare, etc.
    11. Addiction treatment for incarcerated persons: Support evidence-based addiction treatment, including Medication-Assisted Treatment, to persons who are incarcerated in jail or prison.
    12. Reentry Programs: Support programs that connect incarcerated persons to addiction treatment, recovery support, harm reduction services, primary healthcare, or other services or supports they need upon release from jail or prison.
22. Of the 12 strategies, which two does your organization focus on most?*
24. Does your organization supply Narcan?*
    -- Select One --YesNo
25. If yes, about how many doses of Narcan do you distribute in one quarter (3 months)?*
    -- Select One --<5050-100101-200201-300301-400401-500>500
27. What barriers or gaps have you seen or encountered when seeking services (treatment, recovery support, etc.) for clients? (check all that apply) **

    1. Child-care assistance
    2. Employment
    3. Paying for treatment
    4. Services offered in languages other than English

    1. Stigma - Being uncomfortable seeking help
    2. Transportation
    3. Not knowing which services are available
    4. Other (Please Explain)
29. If "Other" was selected for the above question, please explain here:*
31. What are the strengths in your community to help address opioid misuse?*

    1. Resources (e.g. staff, funding, ect.)
    2. Strong Leadership
    3. Key stakeholder involvement
    4. Community partnerships
    5. Treatment services
    6. Public awareness

    1. Education programs
    2. Access to local data in the opioid crisis and opioid related activities
    3. There are no strengths
    4. Don’t know/ not sure
    5. Other (Please Explain)
33. If "Other" was selected for the above question, please explain here:*
35. What are the gaps/challenges in your community to addressing opioid, issue (Choose 3)?*

    1. Lack of resources/funding
    2. Lack of leadership
    3. Key stakeholder involvement missing
    4. Limited partnership/ collaboration
    5. Limited/ lack to treatment services
    6. Limited public awareness
    7. Limited/lack of education programs

    1. Limited/ no access to local data
    2. Too much time/money wasted in government bureaucracy
    3. Too much money going to for profit- entities
    4. There are no challenges
    5. Do not know/ not sure
    6. Other (Please Explain)
37. If "Other" was selected for the above question, please explain here:*
39. In your opinion, what are the biggest needs in your community related to the opioid crisis?*
41. Is there any additional feedback or information you would like to share in regard to the opioid settlement?*
43. Do you believe the Pitt County Action Coalition meeting quarterly would be beneficial for your program/organization?*
    -- Select One --YesNo
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