CAMBODIAN/KHMER

KMnitp∂Ácep∂ImkarkarBarsuxumalPaBkñ¨gshKmn—

karsÊg'mtikñ¨gshKmn—

COALITION NAME

BYkeyIgesñIsMu/ñkcUlrYmkñ¨gkarsÊg'mtienH . karsÊg'mtienHKW/MBIkare®bIe®K]gej«nkñ¨gcMeNamyuvCnkñ¨gshKmn—rbs'BYkeyIg . BYkeyIg nwge®bI®◊s'karsÊg'mtiTaMgenHedIm∫IdwknaMkargarrbs'BYkeyIgbeg˚ItkmµviZIkarkarBarkare®bIe®K]gej«nEdlman®bsiTiÛPaBs®mab'shKmn—rbs'BYkeyIg .

karsÊg'mtienHKW/namik . vamann¤yzaBYkeyIgnwgminsYrBIeQµaH nig/asydƒanrbs'/ñkeT .

karsÊg'mtienHKWedaysµ®¤Kcit∂ . vamann¤yza/ñk/acbdiesZeq¬IysMNYrNamYy …bJŒb'karsÊg'mtieBlNak°◊n . karsÊg'mti®tUvcMNay eBlBI10 – 15naTI .

etI/ñkcg'◊nB¤t·manbEnΩmBIshPaBrbs'eyIgeT? /ñk/acTak'TgBYkeyIg◊ntamTUrs¤BÊ nigtam/Iuem"l .

Phone:

Email:
Website

Community Prevention Wellness Initiative

Community Survey

We are asking you to participate in this survey. The survey is about concerns about substance abuse among youth in our community. We will use these surveys to guide our work to develop effective substance abuse prevention programs for our community.

This survey is anonymous. That means we will not ask for your name or address.

This survey is voluntary. That means that you can refuse to answer any question or stop the survey at any time. The survey will take 10 – 15 minutes.

Would you like more information about our coalition? You can contact us by phone and by email.

TMB¤renHmanectnaTukØ¥TMenr

C/K2014 CPWI Community SurveyOCT 3, 2014

ADMIN: INITIALS #CAMBODIAN

/KHMER

KMnitp∂Ácep∂ImkarkarBarsuxumalPaBkñ¨gshKmn—

karsÊg'mtikñ¨gshKmn—

COALITION NAME

sMnYrdMbUgTaMgenHsYrBIkaryl'eXIjBIkare®bIe®K]gej«nrbs'/ñk nigkar®BYy◊rm∏BIsuxPaBp¬Ëvcit∂kñ¨gshKmn—rbs'/ñk .

1 / etI/ñkKitzabJ˙axage®kamenHZ©n'Z©rb"uNˆakñ¨g cMeNamyuvCn (zñak'TI 6 dl' 12) kñ¨gshKmn—rbs'/ñk? / minEmnCa bJ˙aeT / bJ˙atictYc / bJ˙amZ¥m / bJ˙aZ©n'Z©r / mindwg
kare®bI®◊s'Cati®svwg /  /  /  /  / 
kare®bI®◊s'kJœa /  /  /  /  / 
kare®bI®◊s'zñaMxusBIkarB¥a◊l /  /  /  /  / 
e®K]gej«nepßgeT«t (sUmbJÇak'xage®kam *)
/  /  /  /  / 
karebIkbre®kam≤TiÛBlCati®svwg kJœa …e®K]g ej«nepßgeT«t? /  /  /  /  / 
zñaMCk' /  /  /  /  / 
karZ¬ak'Twkcit∂ /  /  /  /  / 
sm¬ab'x¬Án /  /  /  /  / 
* ebI/ñk◊nKUs “e®K]gej«nepßgeT«t” xagelI etIe®K]gej«nmYyNa? ______
2a / ebIyuvCnmñak' (zñak'TI 6 dl' 12) cg'◊nCati ®svwg etIBYkeK/acTTYl◊ngay®sYlb"uNˆaEdr? / ®sYlNas'
 / ®sYlEdr
 / Bi◊kEdr
 / Bi◊kNas'
 / mindwg

2b / ebIyuvCnmñak' (zñak'TI 6 dl' 12) cg'◊nkJœa etI BYkeK/acTTYl◊ngay®sYlb"uNˆaEdr? /  /  /  /  / 
3 / etI®bCaCnp∂l'kar®bzuydl'x¬ÁnGg nigdl'/ñkd´T eBlBYkeKebIkbr. . . / minmankar®bzuy / kar®bzuytictYctictYc / kar®bzuymZ¥m / kar®bzuyxıs' / mindwg
e®kam≤TiÛBlCati®svwg? /  /  /  /  / 
e®kam≤TiÛBlkJœa? /  /  /  /  / 

C/K2014 CPWI Community Survey CORE-NOTRANOCT 3, 2014 Page 1 of 5

CAMBODIAN/KHMER

sUme/ayeyabl'mti/ñk/MBIkarCMrujc∫ab'kñ¨gshKmn—rbs'/ñk .
yl'®sb x¬aMg / yl'®sb / minyl'®sb / minyl'®sbx¬aMg / mindwg
4 / buK�likCMrujc∫ab'kñ¨gshKmn—rbs'eyIgeZ√Ikarman ®bsiTiÛPaB enAeBlBYkeKeq¬IytbnwgkarehATUrs¤BÊ nigsMeNIBIkare®bI®◊s'Cati®svwg nige®K]gej«n epßgeT«teday/ñkminTan'®Kb'/ayue®bI®◊s'enAkñ¨g BIZICb'el«g …karCYbCMuKña . /  /  /  /  / 

sMNYrTaMgenHsYr/MBI≤riyabz nigTm¬ab'EdlTak'TgnwgyuvCnminTan'®Kb'/ayu (zñak'TI 6 dl' 12) e®bI®◊s'e®K]gej«n .

5 / etI/ñk/nuJÔatØ¥yuvCnpwkCati®svwg (elIsBImYy m"at' ) enApÊHrbs'/ñk…eT?
e®CIserIscem¬IymYy . / 1 eT áminTukCati®svwgkñ¨gpÊHrbs'áeT .
2 eT min/ac .
3 ◊n b"uEn∂kñ¨gOkasBiessEtb"ueNˆaH .
4 ◊n s®mab'EtkUnáb"ueNˆaH mit∂Pk˚iBYkeKmin◊neT .
5 ◊n b"uEn∂e®kamkar®Kb'®Kgrbs'á .
6 ◊n
7 mindwg
6 / etI/ñk/nuJÔatØ¥yuvCne®bI®◊s'kJœaenApÊHrbs'/ñk …eT?
e®CIserIscem¬IymYy . / 1 eT áminTukkJœakñ¨gpÊHrbs'áeT .
2 eT min/ac .
3 ◊n b"uEn∂kñ¨gOkasBiessEtb"ueNˆaH .
4 ◊n s®mab'EtkUnáb"ueNˆaH mit∂Pk˚iBYkeKmin◊neT .
5 ◊n b"uEn∂e®kamkar®Kb'®Kgrbs'á .
6 ◊n
7 mindwg
7 / etI/ñk®tYtBinit¥zñaMtameBT¥ecjO¥EdlyuvCn/ace®bI xus dUcCazñaMbM◊t'karQWcab' zñaMbM◊t'karZ¬ak'Twk cit∂ zñaMs®mab'skmµPaBhYsehtu nigzñaMeZ√IØ¥eKg lk'…eT?
e®CIserIscem¬IymYy . / 1 eT BYkeyIgminEdle®bIzñaMTaMenHeT .
2minEdl
3 eBlx¬H
4 PaKe®cIn
5 EtgEt
6 mindwg
8 / etI/ñks�al'kEn¬ge◊HecalzñaMEdleBT¥ecjO¥enaHenAkñ¨gshKmn—rbs'/ñkeTeBlEdl/ñkQb'e®bIBYkva?
s�al' / /t'eT / mindwg
9 / man®kumsµ®¤Kcit∂kñ¨gshKmn—rbs'/ñkEdleZ√Ikarkat'bnΩykare®bI®◊s'Cati®svwg nigzñaMrbs'yuvCn .
etI/ñks�al'®kum/shPaBenHeT? / s�al' / /t'eT /  mindwg
10 / etI/ñkKitzaKYrEtmanplvi◊ktamp¬Ëvc∫ab'eT ebIb"UlIscab'◊nyuvCn(zñak'TI 6 dl' 12) . . .
KYr / minKYr / mindwg
kMBugpwkCati®svwg? /  /  / 
kMBuge®bI®◊s'kJœa? /  /  / 
11 / etI/ñkKitzaKYrEtmanplvi◊ktamp¬Ëvc∫ab'eT ebIb"UlIscab'◊nmnusßeBjv¤y. . .
KYr / minKYr / mindwg
kMBugp∂l'Cati®svwgdl'yuvCn (zñak'TI 6 dl' 12)? /  /  / 
kMBugp∂l'kJœadl'yuvCn (zñak'TI 6 dl' 12)?" /  /  / 

sMNYrxage®kamKW/MBIPaBCaÅBukm∂ay nigkar◊rm∏karej«nsarZatuej«ncMeBaH/ñkminTan'®Kb'/ayue®bI®◊s' .

12 / etI/ñkCaÅBukm∂ay …/aNaB¥a◊lkUner«nzñak'TI 6 dl' 12 …eT? / Emn / minEmn /  mindwg
[®bsinebIeT …mindwg cUreTAkan'sMNYrTI19]

ebI/ñkmankUnelIsBImñak'er«nzñak'TI 6 dl' 12 sUmKitBIkUnZMCageKbMputrbs'/ñkkñ¨gkareq¬IysMNYrTaMgenH .

13 / kñ¨g/ML¨geBl 3 Exkn¬geTA etI/ñk◊nniyayCamYykUner«nzñak'TI 6 dl' 12 /MBIsk∂anuBl´nplvi◊k/viCÇmanEdlTak'TgCamYy .
◊nniyay / min◊nniyay / mindwg
kare®bI®◊s'Cati®svwgcMeBaH/ñkminTan'®Kb'/ayue®bI®◊s'? /  /  / 
kMBuge®bI®◊s'kJœa? /  /  / 
kMBuge®bI®◊s'zñaMtamevCÇbJÇaEdlminEmnecjØ¥BYkeKe®bI®◊s'? /  /  / 
14 / s®mab'®beyaKnImYy@ sUmbg˙aj zaetI/ñkyl'®sbx¬aMg yl'®sb minyl'®sb …minyl'®sbx¬aMg .
yl'®sb x¬aMg / yl'®sb / minyl'®sb / minyl'®sbx¬aMg / mindwg
á®◊zñazaá◊ndwg/√Il÷edIm∫IniyayCamYykUná/MBI e®K]gej«n (Cati®svwg zñaMCk' kJœa) . /  /  /  /  / 
/√IEdlánwgniyayman≤TiÛBltictYc zaetIkUnáe®bI ®◊s'e®K]gej«n . /  /  /  /  / 
kar/b'rMBIe®K]gej«n®tUv◊neZ√Il÷bMputedaysala minEmnedayÅBukm∂ayeT . /  /  /  /  / 
mankEn¬gCae®cInenAkñ¨gshKmn—á Edlá/ac sikßabEnΩmBIreb«bCYykarBarkUnáBIkare®bI®◊s' e®K]gej«n . /  /  /  /  / 
15 / etIyuvCnp∂l'kar®bzuydl'ragkayx¬ÁnGg nigkñ¨gviZI epßgeT«tk®mitNa eBlEdlBYkeKe®bI®◊s'kJœa mYy …BIrdgkñ¨gmYys◊∂h—? / minmankar®bzuy
 / kar®bzuytictYc
 / kar®bzuymZ¥m
 / kar®bzuyx¬aMg
 / mindwg

16 / etI/ñkKitzaxusb"uNˆa EdlkUn/ñker«nzñak'TI 6 dl' 12. . . / minxuseT / xusbn∂ic / xus / xusx¬aMg / mindwg
pwke®K]g®svwgmYy …BIresÊIrEtral'´z©? /  /  /  /  / 
e®bI®◊s'kJœamYy …BIrdgkñ¨gmYys◊∂h—? /  /  /  /  / 
e®bI®◊s'zñaMtamevCÇbJÇaEdlminEmnecjØ¥BYkeK e®bI®◊s'? /  /  /  /  / 
17 / eBlEdlkUn/ñk (er«nzñak'TI 6 dl' 12) ecje®kAenAeBll©ac …enAcugs◊∂h— etIjwkj"ab'b"uNˆaEdl/ñk –
minEdl / yUr@m∂g / eBlx¬H / CaZmµta / EtgEt
sYreKeTACamYy/ñkNa? /  /  /  /  / 
sYreKeTANa? /  /  /  /  / 
ebIkUnákMBugcUlrYmBiZICb'el«g Binit¥emIlebIBiZI Cb'el«gnwgmanmnusßeBjv¤y®Kb'®KgeT? /  /  /  /  / 
kMNt'em"ags®mab'kUn/ñk®tLb'mkpÊHvij? /  /  /  /  / 
rg'caMrhUtdl'kUn/ñkmkdl'pÊHvij? /  /  /  /  / 
Binit¥emIlebIkUn/ñksΩite®kam≤TiÛBlCati®svwg … e®K]gej«n (niyayCamYyBYkeK hitk¬in nig Binit¥EPñk)? /  /  /  /  / 
18 / etI/ñkKitzajwkj"ab'b"uNˆaEdlÅBukm∂ayPaKe®cInenAkñ¨gshKmn—rbs'/ñkeZ√IdUcxage®kamenH eBlEdlkUnBYkeK (er«nzñak'TI 6 dl' 12) ecje®kAenAeBll©ac …enAcugs◊∂h—?
minEdl / yUr@m∂g / eBlx¬H / CaZmµta / EtgEt
sYreKeTACamYy/ñkNa? /  /  /  /  / 
sYreKeTANa? /  /  /  /  / 
ebIkUnákMBugcUlrYmBiZICb'el«g Binit¥emIlebIBiZI Cb'el«gnwgmanmnusßeBjv¤y®Kb'®KgeT? /  /  /  /  / 
kMNt'em"ags®mab'kUn/ñk®tLb'mkpÊHvij? /  /  /  /  / 
rg'caMrhUtdl'kUn/ñkmkdl'pÊHvij? /  /  /  /  / 
Binit¥emIlebIkUn/ñksΩite®kam≤TiÛBlCati®svwg … e®K]gej«n (niyayCamYyBYkeK hitk¬in Binit¥ EPñk)? /  /  /  /  / 

®bCasa®s∂

19
13 / etI/ñk/ayub"uNˆa? / 18-2425-3435-44
45-5455-6465+
20
14 / etI/ñkmanePT/√I? / ®sI®bus
21
15 / etIedImkMeNIt/ñkCaLaTIne/s∫"aj /LaTIn … e/s∫"ajEmneT? / EmnminEmnmindwg
22
16 / etI/ñkCaCnCati/√I?
KUsral'cem¬IyEdl®tUv . / 1 Es∫ks
2Es∫kexµA …/a®h√ik/aemrik
3CnCatiedIm/aemrik CnCatiedIm/aLas˚a
4/asIu
5CnCatiedImha´v …ekaH◊"sIuh√ikepßgeT«t
6 mindwg/minc∫as'
7epßg@
23
17 / etIPasa/√IEdl/ñkniyayenApÊH?
KUsral'cem¬IyEdl®tUv . / 2 Pasa/g'eK¬s1 PasaExµr
5 Pasae/s∫"aj3 PasarusßI¨
4 PasasUm"alI
6 epßg@
24
18 / etI/ñkmank®mitvb∫Zm·®twmNa? / 1 minEdlcUler«n5cb'viT¥al¤y
2e®kamviT¥al¤y6mincb'sklviT¥al¤y
3mincb'viT¥al¤y7cb'sklviT¥al¤y/mhaviT¥al¤y
4 viT¥al¤y /GED8e®kayot∂m
25
19 / etIhßI¨bkUdrbs'/ñkb"unµan?

sUm/rKuNs®mab'karbMeBjkarsÊg'mti!
karcUlrYmrbs'/ñkKW®tUv◊n/b/r .

etI/ñkcg'dwgbEnΩmBI®kumrbs'BYkeyIgeT? ebIcg' sUmeTATMB¤rbnÊab' . B¤t·manTak'Tgrbs'/ñknwg®tUvTukdac'edayELkBIkarsÊg'mti/namikenH .

C/K2014 CPWI Community Survey CORE-NOTRANOCT 3, 2014 Page 1 of 5

CAMBODIAN/KHMER

TMB¤renHmanectnaTukØ¥TMenr

C/K2014 CPWI Community SurveyOCT 3, 2014

CAMBODIAN/KHMER

COALITION NAME

ebI/ñkcg'dwgbEnΩmBIshPaBrbs'BYkeyIg sUmbJçËlB¤t·manTak'Tgrbs'/ñkxage®kam .

eQµaH

elxTUrs¤BÊ

/asydƒan/uIem"l

B¤t·manTak'Tgnwg®tUvTukdac'edayELkBIkarsÊg'mti/namik

If you would like to hear more about our coalition, please enter your contact information below.

Name

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Contact information is kept separate from the anonymous survey