Incident and Reporter Questions
In this section we will ask for information on the Incident that occurred and some general questions
about you as the Reporter.
Either select from suburbs below or click here to use your current location .
Enter suburb/town/community where the incident occurred
Date of the incident
Which statement best describes you, as the incident reporter? - Service provider Retail business Member of the public Family member or friend AOD Worker Prefer not to say
Please select your organisation sector - Non-government organisation Aboriginal Medical/Health Service Private GP or practice Public health clinic or hospital Mental health service Police Ambulance Security Residential care provider Child Safety Youth Justice Housing Disability / Aged care Department of Education Local business Local council Other
Please select your retail business - Chemist Supermarket (Coles, Woolworths, Aldi) Convenience Store (Night Owl, 7/11) Independent Grocer (IGA) Hardware Store (Bunnings, paint store) Service Station (fuel station) General Store (remote community) Unknown Other
Please specify your organisation/retail sector
Select the option that best describes the type of incident - Young person appeared intoxicated Evidence of use on young person (e.g. paint on clothes) Young person attempted to obtain substance Young person disclosed use Someone else disclosed incident Witnessed young person inhaling Paraphernalia/material found (e.g. empty aerosol cans) Other
Select the option that best describes the incident - Inhalant use on premises Theft or attempted theft of substance Suspicious sale of substance Refused sale of substance Stock loss Nuisance behaviour at premises VSU paraphernalia or material found on premises Other
Please describe the type of incident
Additional information about the incident, please do not include Personally Identifiable Information.
Demographic Questions
In this section we will ask you about the Demographics of the Young Person or Young Persons who you
witnessed or are aware of them partaking in Volitile Substance Use.
If this is not known to you, please leave this section blank. Multiple entries can be made by clicking
the Add button below and your answer will be shown in the table.
Gender of the young person inhaling Unknown/Diverse Male Female
What is the cultural background of the young person/people? Unknown Aboriginal Aboriginal & Torres Strait Islander Torres Strait Islander Caucasian Pacific Islander Asian Middle Eastern Indian Papua New Guinean
Age range of the young person/people Unknown Under 10 10-12 years 13-15 years 16-18 years 19-21 years 21-25 years Over 25 years
How many Young Persons are in this age range?
How often would the young person/people use inhalants (if known)? Unknown Once or twice only Monthly Weekly Daily or almost daily
Demographic Groups Add
Gender
Cultural Background
Age Range
Amount
Frequency of use
Substance Questions
In this section we will ask you questions about the substances used, found, or use of disclosed to you.
As well as questions on the frequency of use and the source from which the substance was acquired.
Please select the source of the substance, if known Unknown Chemist Supermarket (Coles, Woolworths, Aldi) Convenience Store (Night Owl, 7/11) Independent Grocer (IGA) Hardware Store (Bunnings, paint store) Service Station (fuel station) General Store (remote community) Other