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  1. How often do you normally use: (DARKEN ONE BUBBLE FOR EACH LINE: a-l.)

    Never used it Every day Several times a week Several times a month About once a month About once a year Less than once a year
    a. Tobacco?
    b. Alcohol?
    c. Inhalants (whiteout, spray paint, glue, gas, etc.) to get high?
    d. Marijuana?
    e. Cocaine (not crack)?
    f. Crack?
    g. Blamaril?
    h. Steroids
    i. Ecstasy?
    j. Heroin (black tar, cheese, chiva, brown heroin)?
    k. Methamphetamine (speed, crystal meth, ice, or crank)?
    l. Synthetic Marijuana (spice, K2)?


  2. When you drink alcoholic beverages, how many drinks do you usually have AT ONE TIME, on average: (DARKEN ONE BUBBLE FOR EACH LINE: a-d.)

    Never drink this beverage 12 or more drinks 9-11 drinks 5-8 drinks 3-4 drinks 2 drink 1 drink Less than 1 drink
    a. Beer
    b. Wine Coolers (hard lemonade, hard sodas, hard ciders, etc.)
    c. Wine
    d. Liquor (vodka, rum, whiskey, etc.)


  3. IN THE PAST 30 DAYS, on how many days have you had 5 or more drinks of alcohol in a two-hour period?

    Never had 5 or more drinks in two-hour period None 1 day 2 days 3 to 5 days 6 to 9 days 10 or more days
    a. Alcohol


  4. How often do you get alcoholic beverages from the following sources: (DARKEN ONE BUBBLE FOR EACH LINE: a-e.)

    Do Not Drink Never Seldom Most of the time Always
    a. At home
    b. From friends
    c. From a store
    d. At parties
    e. Other source


  5. How dangerous do you think it is for kids your age to use: (DARKEN ONE BUBBLE FOR EACH LINE: a-m)

    Very Dangerous Somewhat Dangerous Not very Dangerous Not Dangerous At All Don't Know
    a. Tobacco?
    b. Alcohol?
    c. Inhalants (Whiteout, spray paint, glue, gas, etc.)?
    d. Marijuana?
    e. Cocaine (not crack)?
    f. Crack?
    g. Ecstasy?
    h. Steroids?
    i. Heroin (black tar, cheese, chiva, brown heroin)?
    j. Methamphetamine (speed, crystal meth, ice, or crank)?
    k. Synthetic Marijuana (spice, K2)
    l. Any prescription drug not prescribed to you?
    m. Electronic Vapor Products (E-Cigarettes, E-Cigars, Vaping Pens, Vape Pipes, etc.)?