Form 0920-1154 Stop Overdose Campaign Evaluation: Fentanyl and Naloxone

[Text Intro – Required to Show to Respondent]

OMB Control No. 0920-1154

Exp. Date 03/31/2026

The public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-1154).

The Centers for Disease Control and Prevention (CDC) developed and launched the Stop Overdose campaigns, four education campaigns, to prevent and reduce drug overdoses. This is research in which you will respond to multiple choice and open-ended questions to give your opinions about Stop Overdose campaign messages and materials. Participation is voluntary and you may complete all or some of the survey. If you have questions about this research, you may contact the principal investigator, Everett L. Long, PhD., by email at [email protected] or phone, (704)-657-5338.

By continuing to the survey, you are indicating your consent for us to collect the information you provide in your responses.

Stop Overdose Campaign Evaluation: Fentanyl and Naloxone Campaigns Survey

S1. Age

What is your age? [SELECT FROM DROP DOWN]

[Terminate if under 18 or over 34]

S2. State

In which state do you reside? [Drop down with states listed]

S3. Zip Code

Please list the zip code where you currently live. [Open End]

[Terminate if NOT New Orleans, Portland, Seattle-Tacoma, or Tampa-St. Petersburg (Sarasota) DMAs]

S4. Media Habits

[Single choice grid]

How often do you do the following on your computer, smartphone, tablet, connected TV, or other streaming devices?

Columns

Daily

A few times a week

About once a week

Less than once a week

Never

Rows

Listen to/stream a podcast

Listen to/stream music

Watch a short video clip

Watch a movie or TV show

S5. Radio

Typically, how often do you listen to AM or FM radio, including both music and talk stations?

Please consider all the ways you might listen to radio, including on a regular radio, in the car, online through your computer, streamed through a phone/tablet/other mobile device, or through a game console, smart speaker or other connected device.

Several times a day

About once a day

Several times a week

A few times a week

About once a week

Less than once a week [Terminate]

S6. Stations

[Multi choice; Randomize]

We’d like to know the radio stations you listen to (again, consider all the ways you might listen to radio). Please indicate which stations you have listened to in the past week.

[New Orleans]

101.1 WNOE (WNOE-FM, 101.1)

News Talk 99.5 (WRNO-FM, 99.5)

Amen 940 New Orleans (WYLD-AM, 940)

98.5 WYLD New Orleans (WYLD-FM, 98.5)

None of these [Terminate]

[Portland]

NewsRadio 1190 KEX (KEX-AM, 1190)

105.9 The Brew (KFBW-FM, 105.9)

K103 (KKCW-FM, 103.3)

Z100 Portland (KKRZ-FM, 100.3)

106.7 The Eagle (KLTH-FM, 106.7)

Rip City Radio 620 (KPOJ-AM, 620)

JAM’N 107.5 (KXJM-FM, 107.5)

None of these [Terminate]

[Seattle-Tacoma]

106.1 KISS FM (KBKS-FM, 106.1)

96.5 Jack FM (KJAQ-FM, 96.5)

95-7 The Jet (KJEB-FM, 95.7)

Sports Radio KJR Seattle (KJR-AM, 950)

1090 The Patriot (KPTR-AM, 1090)

102.5 KZOK (KZOK-FM, 102.5)

None of these [Terminate]

[Tampa-St. Petersburg (Sarasota)]

95.7 The Beat (WBTP-FM, 95.7)

620 WDAE (WDAE-AM, 620)

Newsradio 790 WFLA (WFLA-AM, 970)

93.3 FLZ (WFLZ-FM, 93.3)

US 103-5 (WFUS-FM, 103.5)

1250 WHNZ (WHNZ-AM, 1250)

Mix 100.7 (WMTX-FM, 100.7)

Rumba 106.5 Tampa (WRUB-FM, 106.5)

107.9 WSRZ (WSRZ-FM, 107.9)

Z105 (WTZB-FM, 105.9)

98ROCK (WXTB-FM, 97.9)

None of these [Terminate]

S7. At Risk

Are you or someone you care about currently at risk for opioid misuse or overdose?

Opioid misuse is the use of opioid drugs without a prescription, or in a different way than prescribed by a doctor.

[Single choice]

Yes

No

S8. Interest in Learning More

[Single choice]

How interested are you in learning more information about opioid misuse and reducing drug overdose?

Extremely interested

Very interested

Somewhat interested

Slightly interested

Not at all interested

[Terminate if S7 is “No” AND S8 is “Not at all interested”]

[Text Intro]

The survey is about CDC’s Stop Overdose campaigns. Read each statement and indicate your level of agreement or answer each question by selecting a response.

FENTANYL

Q. Fentanyl Agreement

Please indicate to what extent you agree or disagree with each of the statements below regarding fentanyl.

[Columns]

Strongly agree

Agree

Disagree

Strongly disagree

Don’t know

[Rows]

Fentanyl can cause an overdose

I feel confident I can protect myself from a fentanyl overdose

Fentanyl might be mixed with other drugs such as heroin, cocaine, methamphetamine, and ecstasy

It takes a large amount of fentanyl to overdose

Q. Searched Fentanyl

Have you ever searched for information about fentanyl?

Yes

No

Prefer not to answer

Q. Fentanyl Information [Ask if response to Q. Searched Fentanyl is “Yes”]

What type of fentanyl information have you searched for?

[Multi choice; Randomize]

Effects of fentanyl

Responding to a fentanyl overdose

What is fentanyl

Signs and symptoms of a fentanyl overdose

None of these [Anchor; Exclusive]

Q. Fentanyl Test Strips

Fentanyl test strips are used to determine whether drugs include fentanyl. Please indicate your response to each of the statements below regarding fentanyl test strips.

[Columns]

Yes

No

Don’t know

Prefer not to answer

[Rows]

Have heard of fentanyl test strips

Have ever used a fentanyl test strip

Currently carry or use fentanyl test strips

Q. Plan to Search Fentanyl

Do you plan to seek out further information about the dangers of fentanyl?

Yes

No

Prefer not to answer

NALOXONE

Q. Naloxone Knowledge and Behaviors

Naloxone is a drug that can reverse an overdose from opioids, including heroin, fentanyl, and prescription opioid medications. (You may have also heard of Narcan, a brand of naloxone).

Please indicate your response to each of the statements below regarding naloxone.

[Columns]

Yes

No

Don’t know

Prefer not to answer

[Rows]

I know how to get naloxone in my community

Naloxone is available at a pharmacy I go to

I need a prescription to get naloxone

Q. Searched Naloxone

Have you ever searched for information about naloxone?

Yes

No

Prefer not to answer

Q. Naloxone Agreement

Please indicate to what extent you agree or disagree with each of the statements below regarding naloxone.

[Columns]

Strongly agree

Agree

Disagree

Strongly disagree

Don’t know

[Rows]

Naloxone is easy to use

If I carry naloxone, I could help save a life

Using naloxone in time can help prevent overdose deaths

Q. Naloxone Use and Carry

Please indicate if you have ever done or currently do each of the following.

[Columns]

Yes

No

Don’t know

Prefer not to answer

[Rows]

I have obtained naloxone (purchased, received for free through a health care provider or fire department, etc.)

I have used/administered naloxone to help reverse an overdose

I currently carry/have naloxone or keep it accessible in case of an emergency

Q. Plan to Search Naloxone

Do you plan to seek out further information about naloxone?

Yes

No

Prefer not to answer

Q. Plan to Carry Naloxone

Do you plan to obtain naloxone to carry with you in case of emergency?

Yes

No

Prefer not to answer

Perceptual Feedback

Q. Campaign Recall

[Single choice]

Do you recall seeing or hearing any CDC ads about preventing or reducing drug overdoses?

Yes

No

Not Sure

[If Campaign Recall is “No” or “Not Sure,” skip to note before Demographics]

Q. Ad Recall by Media Channel

[Multi choice; Randomize]

Where do you recall seeing or hearing the CDC ads about preventing or reducing drug overdoses?

Please choose as many as apply.

AM/FM radio (either streaming online or from a tuner at home, work, or in car)

Podcast

Online (not social media)

Social media

TV

Billboards

Other [Anchor]

None of these [Anchor; Exclusive]

Q. Campaign Evaluation

Please respond to the statements below to indicate your perception of the CDC ads about drug overdoses.

To what extent do you agree or disagree with the following?

Columns

Strongly agree

Agree

Disagree

Strongly disagree

Don’t know

Rows

The ads are informative

The ads are engaging

The ads are likable

The ads are clear

Q. Campaign Actions

Which of these statements describe what you will do after being exposed to CDC ads about drug overdoses?

[Multi choice; Randomize]

I will go to the CDC website to find out more information

I will go online to learn more

I will share the information with others

I will talk to others about how to respond to opioid overdoses

I will talk to others about the dangers of fentanyl

I will talk to others about how to obtain naloxone

None of these [Exclusive; Anchor]

Demographics

[Text intro]

Now we’d like to know more about you.

Q. Sex at Birth

What sex were you assigned at birth, on your original birth certificate?

Male

Female

Q. Gender Identity

How do you describe your gender identity?

Male

Female

Male to female transgender (MTF)

Female to male transgender (FTM)

Other gender identity

Q. Sexual Orientation

How do you currently describe yourself (mark all that apply)? 

_ Female 

_ Male 

_ Transgender 

_ I use a different term [free-text] 

_ Prefer not to answer/Decline 

Q. Race

Which of the following best describes your race? (select all that apply):  

-- American Indian or Alaska Native  

-- Asian  

-- Black or African American  

-- Native Hawaiian or Other Pacific Islander  

-- White 

-- Prefer Not to Answer/Decline 

Q. Ethnicity

Which of the following best describes your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

Prefer Not to Answer/Decline

Q. HH Income

Last year, that is in 2022, what was your total household income from all sources, before taxes?

Less than $15,000

$15,000 to $24,999

$25,000 to $34,999

$35,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000+

Prefer not to answer

Q. Education

What is the highest level of education you have completed?

Some high school

High school diploma

Some college or associate's degree

Bachelor’s degree

Advanced degree

Q. Illicit Drugs P3M

In the last 3 months, have you used illicit drugs at least once? When referring to illicit drugs, this includes drugs such as cocaine, methamphetamine, ecstasy or molly, opioids, heroin, fentanyl, or misuse of prescription opioids. This does not include alcohol or marijuana alone.

Yes

No

Prefer not to answer

[If “No” or “Prefer Not to Answer” skip to Q. Illicit Drugs Ever]

Q. Illicit Drugs Together P3M

In the past 3 months, have you intentionally taken more than one illicit drug, either together or within a short period of time?

Yes

No

Prefer not to answer

Q. Illicit Drugs Taken Together (Mixing Drugs)

Have you ever intentionally taken more than one illicit drug, either together or within a short period of time?

Yes

No

Prefer not to answer

Q. Drug Use Impact

Does your use of drugs cause health problems, disability, or challenges with major responsibilities at work, school, or home?

Yes

No

Prefer not to answer

Q. Diagnosis

In the last year, have you been diagnosed with, or in recovery or treatment for a substance use disorder?

Yes

No

Prefer not to answer

Q. Friend or Family Member

Do you have a close friend or family member who, in the last 3 months, has used illicit drugs at least once? When referring to illicit drugs, this includes drugs such as cocaine, methamphetamine, ecstasy or molly, opioids, heroin, fentanyl, or misuse of prescription opioids. This does not include alcohol or marijuana alone.

Yes

No

Prefer not to answer

Q. Friend or Family Member Overdose

Do you have a close friend or family member who died from a drug overdose?

[Single choice]

Yes

No

Prefer not to answer

[END SURVEY NOTE]

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