Survey on Opioid Awareness
For Information onlyThis is an electronic survey example for information purposes only. This is not a working questionnaire.
Table of Contents
Demographics (DEM)
Demographics (DEM) - Question identifier:DEM_Q05
What was your sex at birth?
Sex refers to sex assigned at birth.
- 1: Male
- 2: Female
Demographics (DEM) - Question identifier:DEM_Q10
What is your gender?
Gender refers to current gender which may be different from sex assigned at birth and may be different from what is indicated on legal documents.
- 1: Male
- 2: Female
- 3: Or please specify
Demographics (DEM) - Question identifier:DEM_Q15
What is your age group?
- 01: 18 to 19 years
- 02: 20 to 24 years
- 03: 25 to 29 years
- 04: 30 to 34 years
- 05: 35 to 39 years
- 06: 40 to 44 years
- 07: 45 to 49 years
- 08: 50 to 59 years
- 09: 60 to 69 years
- 10: 70 to 79 years
- 11: 80 years and over
Demographics (DEM) - Question identifier:DEM_Q20
To determine which geographic region you live in, please provide your postal code.
Long Answer Length = 6
Postal code
Example: A9A 9A9
Opioid Content (OPI)
Opioid Content (OPI) - Question identifier:OPI_R05
This survey aims to better understand Canadians' awareness of opioids.
Opioids are pain medications, mostly available by prescription.
Some questions may be sensitive in nature, but all your answers will remain strictly confidential.
Opioid Content (OPI) - Question identifier:OPI_Q05
What is your level of awareness about the opioid issue in Canada?
- 1: Very aware
- 2: Somewhat aware
- 3: Not at all aware
Opioid Content (OPI) - Question identifier:OPI_Q10
Where have you learned about the opioid issue in Canada?
Select all that apply.
- 1: Media
- 2: Public awareness campaign
- 3: Government website
- 4: Other Internet sites
- 5: Friends or family
- 6: Other
Opioid Content (OPI) - Question identifier:OPI_Q15
In the past five years, have you used any products containing opioids, such as codeine, oxycodone, OxyContin, hydromorphone, morphine, fentanyl, methadone, Tylenol 3, naloxone, Percocet, Percodan, Tylox and heroin for either medical or recreational purposes?
Exclude Tylenol 1, 222s, Aspirin, Advil, regular Tylenol, or Celebrex.
- 1: Yes
- 2: No
- 3: Prefer not to say
- 9: DK
Opioid Content (OPI) - Question identifier:OPI_Q25
Where did you obtain these products?
Select all that apply.
- 01: Directly from a health care professional, such as a doctor, pharmacist or dentist
- 02: Family
- 03: Friends
- 04: Stranger
- 05: Internet
- 06: Other source
- 07: Don't know
- 08: Prefer not to say
Opioid Content (OPI) - Question identifier:OPI_Q30
Considering the last time you used opioids, what did you do with any left-over pills, liquids or patches?
Select all that apply.
- 01: Had no left-over pills, liquids or patches (Include ongoing use.)
- 02: Returned them to pharmacy or health care professional
- 03: Gave them to someone else who needed them
- 04: Flushed them or disposed them in garbage
- 05: Stored in medicine cabinet
- 06: Stored them somewhere else in the home
- 07: Did something else with them
- 08: Don't know
- 09: Prefer not to say
Opioid Content (OPI) - Question identifier:OPI_Q35
Thinking about the left-over pain killers you stored at home, what was the reason that you did not dispose of them?
Select all that apply.
- 1: For my own use at a later time
- 2: For use by my family and friends, if needed
- 3: I did not know how to dispose of them
- 4: I forgot to dispose them
- 5: Other
- 6: Don't know
- 7: Prefer not to say
Opioid Content (OPI) - Question identifier:OPI_R40
Indicate whether you agree or disagree with the following statements.
Opioid Content (OPI) - Question identifier:OPI_Q40A
If I had opioids, I would share my opioids to relieve the pain of a family member or friend
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q40B
If I had opioids, I would share my opioids to help family members or friends coping with stress or other problems
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q40C
If I had opioids, I would share my opioids for non-medicinal or recreational use
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q40D
If I was prescribed opioids, I would not want my family members or friends to know
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q40E
If I used opioids without a prescription, I would not want my family members or friends to know
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q40F
If I used opioids, there could be a risk of developing an opioid dependency or an opioid use disorder
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q40G
I would feel comfortable seeking help or treatment for an opioid dependency or an opioid use disorder
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_R45
Indicate whether you agree or disagree with the following statements.
Opioid Content (OPI) - Question identifier:OPI_Q45A
I would recognize the signs of an opioid overdose
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q45B
I would call 9-1-1 if I was witnessing a suspected opioid overdose
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q45C
I would know what to do if I was witnessing a suspected opioid overdose
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q45D
I would know how to obtain Naloxone
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_Q45E
I would know how to administer Naloxone
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
Opioid Content (OPI) - Question identifier:OPI_R50
Indicate whether you agree or disagree with the following statements.
Opioid Content (OPI) - Question identifier:OPI_Q50A
Harm reduction services are available in my community
e.g., needle exchange or supervised consumption sites
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
- 9: DK
Opioid Content (OPI) - Question identifier:OPI_Q50B
Treatment options for an opioid dependency or problematic drug use are available in my community
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
- 9: DK
Opioid Content (OPI) - Question identifier:OPI_Q50C
Harm reduction services have public health benefits
e.g., needle exchange services or supervised consumption sites
- 1: Agree
- 2: Neither agree nor disagree
- 3: Disagree
- 9: DK
Opioid Content (OPI) - Question identifier:OPI_R55
Please indicate your level of awareness with the following statements.
Opioid Content (OPI) - Question identifier:OPI_Q55A
Using opioids, even for medicinal purposes, can impair driving a motor vehicle
- 1: Very aware
- 2: Somewhat aware
- 3: Not at all aware
Opioid Content (OPI) - Question identifier:OPI_Q55B
Left-over opioids should be returned to a pharmacy for disposal
- 1: Very aware
- 2: Somewhat aware
- 3: Not at all aware
Opioid Content (OPI) - Question identifier:OPI_Q55C
Problematic use of opioids can lead to an overdose or death
- 1: Very aware
- 2: Somewhat aware
- 3: Not at all aware
Opioid Content (OPI) - Question identifier:OPI_Q55D
Mixing opioids with alcohol can magnify adverse effects, including a possible overdose
- 1: Very aware
- 2: Somewhat aware
- 3: Not at all aware
Opioid Content (OPI) - Question identifier:OPI_Q55E
Mixing opioids with other medications can magnify adverse effects, including a possible overdose
- 1: Very aware
- 2: Somewhat aware
- 3: Not at all aware
Opioid Content (OPI) - Question identifier:OPI_Q55F
Drugs obtained illegally or on the street have the potential to contain fentanyl
- 1: Very aware
- 2: Somewhat aware
- 3: Not at all aware
Opioid Content (OPI) - Question identifier:OPI_Q55G
There is new legal protection (under the Good Samaritan Drug Overdose Act) for people who seek emergency help for someone who has overdosed
- 1: Very aware
- 2: Somewhat aware
- 3: Not at all aware
Opioid Content (OPI) - Question identifier:OPI_R60A
Please indicate, including yourself, the number of your household members that fall within each age group.
Enter a '0' if there are no household members in that age group.
Opioid Content (OPI) - Question identifier:OPI_R60B
Age group
Opioid Content (OPI) - Question identifier:OPI_R60C
Number of members in your household
Opioid Content (OPI) - Question identifier:OPI_Q60A
Under 12 years
Min = 0; Max = 99
Opioid Content (OPI) - Question identifier:OPI_Q60B
12 to 14 years
Min = 0; Max = 99
Opioid Content (OPI) - Question identifier:OPI_Q60C
15 to 17 years
Min = 0; Max = 99
Opioid Content (OPI) - Question identifier:OPI_Q60D
18 to 24 years
Min = 0; Max = 99
Opioid Content (OPI) - Question identifier:OPI_Q60E
25 to 49 years
Min = 0; Max = 99
Opioid Content (OPI) - Question identifier:OPI_Q60F
50 years and older
Min = 0; Max = 99
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