Sample Survey
YOUTH SURVEY
FORM NUMBER ONE
Please answer the following questions on the answer sheet, but do not write on this form. And remember, there are no right or wrong answers. Let's begin.
- Please fill in on your Scantron sheet the number of the form you are completing.
1. Form 1
2. Form 2
3. Form 3
What is your race/culture? Answer yes to all that apply. (For example, if you are both American Indian and White, mark yes to both questions.)
No Yes
- 1 2 Mexican American, Mexican, Chicano
- 1 2 Other Hispanic (Puerto Rican, Cuban, etc.)
- 1 2 White (Anglo)
- 1 2 African American (Black)
- 1 2 American Indian (Pima, Yaqui, Navajo, etc.)
- 1 2 Asian or Pacific Islander (Chinese, Japanese, etc.)
- When talking with family members, what language do you usually speak? (Please fill in only one answer.)
1. Spanish only
2. Mostly Spanish
3. Both English and Spanish, about equal
4. Mostly English
5. English only
6. Other language
- What grades do you usually get in school?
1. Mostly A's
2. A's and B's
3. Mostly B's
4. B's and C's
5. Mostly C's
6. C's and D's
7. Mostly D's
8. D's and F's
9. Mostly F's
- How fast can you READ in the language used in this survey?
1. Very fast
2. Fast
3. Moderately fast
4. A little slow
5. Slow
- When you talk with friends, what language do you usually speak? (Please fill in only one answer.)
1. Spanish only
2. Mostly Spanish
3. Both English and Spanish, about equal
4. Mostly English
5. English only
6. Other language
- How far do you think you will get in school? Do you think you will: (Please fill in only one answer)
1. Finish 4 years of college
2. Finish 2 years of college
3. Finish a trade school or vocational school program
4. Finish high school
5. Finish 8th grade
Questions 13 - 18 relate to the race/culture you chose in question 2 - 7.
- I like to do things that people of my race/culture do.
1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
- I usually talk like other people from my race/culture.
1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
- If I could choose, I would still be of my race/culture.
1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
- Sometimes I am embarrassed by the way people from my race/culture talk.
1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
- People from my race/culture do not know how to act.
1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
- I feel good about being from my race/culture.
1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
- How many drinks of alcohol have you had in your entire life? [1 bottle or can of beer = 1 glass of wine = 1 shot of hard liquor]
1. None. I have never had even one sip of alcohol.
2. Only sips FOR RELIGIOUS SERVICES
3. Only sips (NOT for religious services)
4. Part or all of one drink
5. 2 to 4
6. 5 to 11
7. 12 to 25
8. 26 to 50
9. 51 to 100
10. More than 100
- How many cigarettes have you smoked in your entire life?
1. None. I have never had even one puff.
2. Only one puff
3. Part or all of one cigarette
4. 2 or 3 cigarettes
5. 4 or 5 cigarettes
6. 6 to 10 cigarettes
7. 11 to 20 cigarettes [20 cigarettes = 1 pack]
8. 1 to 5 packs
9. 6 to 20 packs
10. More than 20 packs
- How many times have you used marijuana in your entire life?
1. Never. I have never used marijuana even once.
2. Once
3. 2 or 3 times
4. 4 to 7 times
5. 8 to 15 times
6. 16 to 30 times
7. More than 30 times
- Have you ever used smokeless tobacco (chewing tobacco or snuff) in your whole life?
1. No, never
2. Yes, once
3. Yes, more than once
- Have you ever used cocaine, crack, LSD, PCP, heroin, or downers in your life?
1. No, never
2. Yes, once
3. Yes, more than once
- Have you ever used uppers (speed, crystal meth) in your life?
1. No, never
2. Yes, once
3. Yes, more than once
- Have you ever used inhalants (sniffing gasoline, spray, glue) in your life?
1. No, never
2. Yes, once
3. Yes, more than once
- How many drinks of alcohol have you had in the past 30 days?
1. None.
2. Only sips FOR RELIGIOUS SERVICES
3. Only sips (NOT for religious services)
4. Part or all of one drink
5. 2 or 3
6. 4 to 7
7. 8 to 15
8. 16 to 30
9. More than 30
- How many days in the past 30 days have you had alcohol to drink (do NOT count for religious services)?
1. None
2. One
3. 2 or 3
4. 4 to 7
5. 8 to 15
6. 16 to 30
- How many cigarettes have you smoked in the past 30 days?
1. None
2. Only one puff
3. Part or all of one cigarette
4. 2 or 3 cigarettes
5. 4 to 10 cigarettes
6. 11 to 20 cigarettes [20 cigarettes = 1 pack]
7. 21 to 40 cigarettes [40 cigarettes = 2 packs]
8. More than two packs
- How many days in the last 30 days have you smoked cigarettes?
1. None
2. One
3. 2 or 3
4. 4 to 7
5. 8 to 15
6. 16 to 30
- Is it OK for someone your age to drink alcohol?
1. Definitely OK
2. OK
3. Not OK
4. Definitely not OK
- Is it OK for someone your age to smoke cigarettes?
1. Definitely OK
2. OK
3. Not OK
4. Definitely not OK
- Is it OK for someone your age to use marijuana?
1. Definitely OK
2. OK
3. Not OK
4. Definitely not OK
- If someone offered you alcohol to drink (beer, wine, hard liquor), what would you say?
1. Definitely no
2. No
3. Yes
4. Definitely yes
- If someone offered you a cigarette, what would you say?
1. Definitely no
2. No
3. Yes
4. Definitely yes
- If someone offered you marijuana, what would you say?
1. Definitely no
2. No
3. Yes
4. Definitely yes
- How many hits of marijuana have you had in the last thirty days?
1. None
2. One hit, but a really small one
3. One hit
4. 2 or 3 hits
5. 4 to 10 hits
6. 11 to 20 hits
7. 21 to 40 hits
8. More than 40
- How many days in the last 30 days have you smoked marijuana?
1. None
2. One
3. 2 or 3
4. 4 to 7
5. 8 to 15
6. 16 to 30
- Do you get a free school lunch or a reduced cost school lunch?
1. Free lunch
2. Reduced lunch
3. Neither
- If you were to guess how many students in your school have tried alcohol, tobacco, and other drugs at least once, how many would that be?
1. Most
2. Half
3. Some
4. Hardly any
- How many kids in your school do you think use drugs regularly?
1. Most
2. Half
3. Some
4. Hardly any
- In how many of the following activities do you regularly participate? (For example, if you participate in any three of the following categories of activities, mark the number 3 on your sheet. If you participate in nine or more, mark 9; if you don't participate in any activities, mark number 10.)
- Sports or cheerleader
- Arts and crafts
- Theater
- Band, choir or music lessons
- Boy Scouts, Girl Scouts, or Explorers
- Boys and Girls Club
- Church youth group
- Karate or other martial arts
- Other school clubs, church groups, or community activities
CHECK YOUR SCANTRON SHEET RIGHT NOW: Did you just fill in # 41? If yes, you're on the right line. If no, please go back and check to see if you've missed a question.
- (A1) Do your parents allow you to drink alcohol at parties?
1. All the time
2. Most of the time
3. Sometimes
4. Never
- (A2) How old were you when you first had a drink of alcohol? (more than just sips of beer, wine, or hard liquor)
1. 7 or younger
2. 8
3. 9
4. 10
5. 11
6. 12
7. 13
8. 14 or older
9. I have never used nor tried alcohol even once.
- (A3) How close are you to your parent(s)?
1. Not at all close
2. A little close
3. Neutral
4. Close
5. Very close
Questions 45 - 48 refer to the different ways you might have turned down offers of cigarettes in the past, and which way or ways you like to use.
- (A4) If you turned down cigarettes in the past, how often did you turn down the offer by giving an explanation or some other excuse?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned them down another way.
6. I was not offered cigarettes.
7. I have accepted cigarettes in the past.
- (A5) In the past, how often did you intentionally decide to stay away from situations where you knew people your age were smoking?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
- (A6) If you turned down cigarettes in the past, how often did you turn down the offer by just leaving the situation?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned them down another way.
6. I was not offered cigarettes.
7. I have accepted cigarettes in the past.
- (A7) If you turned down cigarettes in the past, how often did you turn down the offer by just saying no?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned them down another way.
6. I was not offered cigarettes.
7. I have accepted cigarettes in the past.
- (A8) If a friend you really like offered you cigarettes, alcohol, or marijuana, how sure are you that you would say NO?
1. Not at all sure
2. A little sure
3. Somewhat sure
4. Pretty sure
5. Very sure
- (A9) How often do you do things you've been told not to do?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (A10) What is your religion? Fill in the appropriate circle.
1. Catholic
2. Protestant (Methodist, Baptist, AME, etc.)
3. Latter Day Saints/Mormon
4. American Indian Church
5. Jewish
6. Muslim
7. Other religion
8. I don't practice any religion
9. I don't believe in any religion
- (A11) How angry would your parent(s) be if they found out you smoked marijuana?
1. Not angry at all
2. A little angry
3. Pretty angry
4. Very angry
- (A12) How many of your friends use alcohol, cigarettes, chewing tobacco, or marijuana at least once a month?
1. None
2. 1
3. 2
4. 3
5. 4
6. 5 or more
- (A13) What is the highest level of education that your mother completed?
1. Did not attend high school
2. Completed some high school, but did not finish high school
3. Graduated high school (or received GED)
4. Some college, but no degree
5. 2-year college degree (associate's degree)
6. 4-year college degree (bachelor's degree)
7. Some graduate school, but no graduate degree
8. Master's degree or professional degree
9. Ph. D, MD, or JD
10. I don't know
- (A14) How much does your father work right now? (Please pick the answer that best describes how often your father works.)
1. Employed full time
2. Employed part time
3. Unemployed
4. Retired
5. I don't know
6. My father is unable to work
7. My father is not living
- (A15) Is it OK for people to sniff gasoline, glue, or spray?
1. Definitely OK
2. OK
3. Not OK
4. Definitely not OK
- (A16) How often do your parents ask where you are going when you leave the house?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (A17) Teachers help me with schoolwork outside of class.
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (A18) How angry would your parent(s) be if they found out you smoked cigarettes?
1. Not angry at all
2. A little angry
3. Pretty angry
4. Very angry
- (A19) Does drinking alcohol make it easier to be part of a group?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (A20) How would your best friends act toward you if you smoked marijuana?
1. Very friendly
2. Pretty friendly
3. A little unfriendly
4. Very unfriendly
CHECK YOUR SCANTRON SHEET RIGHT NOW: Did you just fill in # 61? If yes, you're on the right line. If no, please go back and check to see if you've missed a question.
- (B1) How often do your parents not let you go places and do things with other people your age?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (B2) Do you think that smoking cigarettes makes people less nervous?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (B3) What is the highest level of education that your father completed?
1. Did not attend high school
2. Completed some high school, but did not finish high school
3. Graduated high school (or received GED)
4. Some college, but no degree
5. 2-year college degree (associate's degree)
6. 4-year college degree (bachelor's degree)
7. Some graduate school, but no graduate degree
8. Master's degree or professional degree
9. Ph. D, MD, or JD
10. I don't know
- (B4) Have you ever been offered uppers (speed, crystal meth)?
1. No, never
2. Yes, in the past 30 days
3. Yes, but not in the past 30 days
- (B5) How involved are you with your religion?
1. Very involved
2. Involved
3. Somewhat involved
4. Involved just a little
5. Not at all involved
- (B6) Do you think that drinking alcohol makes parties more fun?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
Questions 71 - 74 refer to the different ways you might have turned down offers of marijuana in the past, and which way or ways you like to use.
- (B7) If you turned down marijuana in the past, how often did you turn down the offer by giving an explanation or some other excuse?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned it down another way.
6. I was not offered marijuana.
7. I have accepted marijuana in the past.
- (B8) In the past, how often did you intentionally decide to stay away from situations where you knew people your age were smoking marijuana?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
- (B9) If you turned down marijuana in the past, how often did you turn down the offer by just leaving the situation?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned it down another way.
6. I was not offered marijuana.
7. I have accepted marijuana in the past.
- (B10) If you turned down marijuana in the past, how often did you turn down the offer by just saying no?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned it down another way.
6. I was not offered marijuana.
7. I have accepted marijuana in the past.
- (B11) Do you think it is OK for people to try LSD, crack, or cocaine?
1. Definitely OK
2. OK
3. Not OK
4. Definitely not OK
- (B12) Do most of your friends think it is OK for people to sniff gasoline, glue, or spray?
1. Definitely OK
2. OK
3. Not OK
4. Definitely not OK
- (B13) How do you think your best friends would act toward you if you smoked cigarettes?
1. Very friendly
2. Pretty friendly
3. A little unfriendly
4. Very unfriendly
- (B14) How old were you when you first smoked a cigarette? (more than just puffs)
1. 7 or younger
2. 8
3. 9
4. 10
5. 11
6. 12
7. 13
8. 14 or older
9. I have never smoked nor tried it even once.
- (B15) I really feel like I belong in this school.
1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
- (B16) Who has taught you the most about the negative effects of alcohol and other drugs?
1. Mom
2. Dad
3. Brother/sister or cousin
4. Grandparent
5. Aunt or Uncle
6. Friends
7. School
8. TV, movies, radio
9. Church group or other groups
10. No one
- (B17) When you are curious about drugs, whom do you feel the most comfortable talking with?
1. Boyfriend or girlfriend
2. Close friends
3. Kids you know in school
4. Brother, sister, or cousin
5. Mom
6. Dad
7. Uncle, aunt, grandparent, other relative
8. Teacher
- (B18) How often do your parents allow you to go out whenever you want to?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (B19) Have you ever been offered cocaine, crack, LSD, PCP, heroin, or downers?
1. No, never
2. Yes, in the past 30 days
3. Yes, but not in the past 30 days
CHECK YOUR SCANTRON SHEET RIGHT NOW: Did you just fill in # 80? If yes, you're on the right line. If no, please go back and check to see if you've missed a question.
- (C1) When you go out with your friends, how often do your parents tell you what time to be home?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (C2) If someone you don't know very well offered you cigarettes, alcohol, or marijuana, how sure are you that you would say NO?
1. Not at all sure
2. A little sure
3. Somewhat sure
4. Pretty sure
5. Very sure
Questions 84 - 87 refer to the different ways you might have turned down offers of alcohol in the past, and which way or ways you like to use.
- (C3) If you turned down alcohol in the past, how often did you turn down the offer by giving an explanation or some other excuse?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned it down another way.
6. I was not offered alcohol.
7. I have accepted alcohol in the past.
- (C4) In the past, how often did you intentionally decide to stay away from situations where you knew people your age were drinking alcohol?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
- (C5) If you turned down alcohol in the past, how often did you turn down the offer by just leaving the situation?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned it down another way.
6. I was not offered alcohol.
7. I have accepted alcohol in the past.
- (C6) If you turned down alcohol in the past, how often did you turn down the offer by just saying no?
1. Most of the time
2. Often
3. Sometimes
4. Rarely
5. I turned it down another way.
6. I was not offered alcohol.
7. I have accepted alcohol in the past.
- (C7) How would your best friends act toward you if you drank alcohol?
1. Very friendly
2. Pretty friendly
3. A little unfriendly
4. Very unfriendly
- (C8) How angry would your parent(s) be if they found out you drank alcohol?
1. Not angry at all
2. A little angry
3. Pretty angry
4. Very angry
- (C9) Have you ever been offered inhalants (sniffing gasoline, spray, glue)?
1. No, never
2. Yes, in the past 30 days
3. Yes, but not in the past 30 days
- (C10) How much does your mother work right now? (Please pick the answer that best describes how often your mother works.)
1. Employed full time
2. Employed part time
3. Unemployed
4. Retired
5. I don't know
6. My mother is unable to work
7. My mother is not living
- (C11) Is it worth getting into trouble to have fun?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (C12) Does smoking marijuana make food taste better?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (C13) Do most of your friends think it is OK for someone your age to smoke cigarettes?
1. Definitely OK
2. OK
3. Not OK
4. Definitely not OK
- (C14) How often do your parents tell you they are proud of you?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (C15) Does drinking make it easier to have a good time with friends?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
- (C16) If a family member (parent(s), brothers, sisters, aunts, uncles, etc.) offered you cigarettes, alcohol, or marijuana, how sure are you that you would say NO?
1. Not at all sure
2. A little sure
3. Somewhat sure
4. Pretty sure
5. Very sure
- (C17) Do most of your friends think it is OK for people to try LSD, crack, or cocaine?
1. Definitely OK
2. OK
3. Not OK
4. Definitely not OK
- (C18) How old were you when you first smoked marijuana?
1. 7 or younger
2. 8
3. 9
4. 10
5. 11
6. 12
7. 13
8. 14 or older
9. I have never used nor tried marijuana even once.
- (C19) Does smoking cigarettes make it easier to concentrate?
1. Most of the time
2. Often
3. Sometimes
4. Almost never
5. Never
You are now done with the survey.
Thank you for your time!!!