Survey for community members

The (insert council) is concerned about the consumption of alcohol products in our community. Alcohol fuels violence and chronic diseases, and causes significant harm to individuals, families and communities. We know you want our community to be a healthy and safe place to live, so we would like to hear your thoughts on this issue. In appreciation of your time, we will offer $100 Coles/Myer vouchers to two randomly selected survey respondents.

The (insert council) includes the suburbs of (list).

If you would like to discuss this project with the (insert council), you can contact (insert).

This survey will remain open until (insert date).

Q1. Have you ever been affected by people’s use of alcoholic products within the (insert council)? If yes, please indicate the effects below.

  • Environmental impacts (noise, property damage) Feeling of being unsafe
  • Violence
  • Family violence
  • I have not been affected

Other – please specify:

___________________________________________________________________

Q2. Are there certain places or settings in the City/Shire where you feel that the drinking of alcohol is a problem?

  • Yes
  • No
  • Unsure

If you stated yes, please provide a specific location:

___________________________________________________________________

Q3. What types of harms do alcohol products fuel in these settings or places? Tick all that apply.

  • Underage drinking
  • High risk drinking
  • Violence
  • Drink driving
  • Family violence
  • Environmental harms (such as litter, property destruction)
  • Other – please specify:

________________________________________________________________

Q4. Do you think communities should have more control over how alcohol products are marketed and sold in these settings?

  • Yes
  • No
  • Unsure

If yes, would you like to make comment?

________________________________________________________________

Q5. Are you concerned that alcohol product availability is increasing, making it easier to access a broad range of alcohol products in the (insert council)?

  • Yes
  • No

Would you like to comment?

________________________________________________________________

Q6. Are you concerned about the influence the alcohol industry has on alcohol product availability in the (insert council)?

  • Yes
  • No

Would you like to comment?

________________________________________________________________

Q7. If the (insert council) could do one thing to prevent harms associated with alcohol product consumption, what do you think that should be?

________________________________________________________________

Q8. Are there any other issues or locations you would like to discuss that relate to the consumption of alcohol products in the (insert council)?

________________________________________________________________

Q9. What is your age?

  • 18 to 24
  • 25 to 34
  • 35 to 44
  • 45 to 54
  • 55 to 64
  • 65 to 74
  • 75 or older

Q10. What is your gender?

________________________________________________________________

Q11. What is your residential postcode?

________________________________________________________________

Q12. If you would like to go into the draw to win one of the two Coles/Myer vouchers, please enter your name and email address or mailing address.

  • Name:
  • Address/email:

Thank you for your time.

This tool was developed with the support, expertise and guidance of Dr Melissa Stoneham.

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