B-1 Youth Community Survey Form

**Form Approved**

> **OMB No.: 09300230**

**     Expiration Date:  12/31/2008**

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Youth Community Survey Form

(Youth ages 12--17)

Use this **Youth Community Survey Form** for surveys of communities in
which data may be collected at a single point in time or at multiple
time points, each time using different samples of individuals rather
than a matched pretest/posttest design.

Public Burden Statement: An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. The OMB control number
for this project is 0930-0230. Public reporting burden for this
collection of information is estimated to average 1 hour per client per
year, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to SAMHSA
Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville,
Maryland 20857.

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Youth Community Survey Form

**This survey is voluntary. If you choose to take it, you may skip any
question you don't want to answer.**

This survey asks about your experience and opinion on a number of things
related to alcohol, tobacco, and drug use. Your answers to these
questions will be confidential. That means no one will connect your
answers with your name or any other information about you that can
identify who you are. To help us keep your answers secret, please do not
write your name on this survey form.

The information in this survey will be used to learn more about the
effectiveness of programs in preventing substance abuse and protecting
youth.

This is not a test, so there are no right or wrong answers. Some
questions may ask you to select all of the answers that are relevant,
and others ask you to select a single answer. If the question asks for a
single answer and you don't find an answer that exactly fits, choose one
that comes closest.

**Thank you for agreeing to participate in this survey.**

RECORD MANAGEMENT: Your survey administrator will tell you what to fill
in for these administrative questions. You may leave all but **Date
Completed** blank if you are not given any instructions.

**Participant ID**

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

**Contract/Grant ID**

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

**Date Completed**

  ----------------- -------- ----------------- -------- -----------------
                    /                          /        

  Month                      Day                        Year
  ----------------- -------- ----------------- -------- -----------------

Program Name

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**Cohort** Number

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **These questions ask for general information about you. Please mark
  the response that best describes you.**

  -----------------------------------------------------------------------

1.  **What is your gender? (Check one)\
    ** Male Female

2.  **Are you Hispanic or Latino? (Check one)**\
    Yes No

3.  **What is your race? (Select one or more)\
    ** White\
    Black or African American\
    American Indian\
    Native Hawaiian or Other Pacific Islander\
    Asian\
    Alaska Native

4.  What is your date of birth?

  --------------------- ------- ---------------- ------- ------------------
                        /                        /       

  Month                         Day                      Year
  --------------------- ------- ---------------- ------- ------------------

  -----------------------------------------------------------------------
  **The next few questions ask about your use of and attitudes toward
  tobacco,\
  alcohol, and other substances.**

  -----------------------------------------------------------------------

**5. Think back over the past 30 days and report how many days, if any,
you used the following substances:**

+------------------------+-----+--------------------+---------+--------+
|                        |     |                    | Fill in | Check  |
|                        |     |                    | number  | if     |
|                        |     |                    | of      | don't  |
|                        |     |                    | days\   | know   |
|                        |     |                    | (0--30) | or     |
|                        |     |                    |         | can't  |
|                        |     |                    |         | say    |
+------------------------+-----+--------------------+---------+--------+
| **Cigarettes:**        | 5a. | During the past 30 |         |        |
| Include menthol and    |     | days, on how many  |         |        |
| regular cigarettes and |     | days did you smoke |         |        |
| loose tobacco rolled   |     | part or all of a   |         |        |
| into cigarettes        |     | cigarette?         |         |        |
+------------------------+-----+--------------------+---------+--------+
| **Other tobacco        | 5b. | During the past 30 |         |        |
| products:** Include    |     | days, on how many  |         |        |
| any tobacco product    |     | days did you use   |         |        |
| other than cigarettes  |     | other tobacco      |         |        |
| such as snuff, chewing |     | products?          |         |        |
| tobacco, and smoking   |     |                    |         |        |
| tobacco from a pipe    |     |                    |         |        |
+------------------------+-----+--------------------+---------+--------+
| **Alcoholic            | 5c. | During the past 30 |         |        |
| beverages:** Include   |     | days, on how many  |         |        |
| beer, wine, wine       |     | days did you drink |         |        |
| coolers, malt          |     | one or more drinks |         |        |
| beverages, and liquor  |     | of an alcoholic    |         |        |
|                        |     | beverage?          |         |        |
+------------------------+-----+--------------------+---------+--------+
| **Marijuana or         | 5d. | During the past 30 |         |        |
| hashish:** Also known  |     | days, on how many  |         |        |
| as grass, pot, hash,   |     | days did you use   |         |        |
| or hash oil            |     | marijuana or       |         |        |
|                        |     | hashish?           |         |        |
+------------------------+-----+--------------------+---------+--------+
| **Other illegal        | 5e. | During the past 30 |         |        |
| drugs:** Include       |     | days, on how many  |         |        |
| substances like:       |     | days did you use   |         |        |
|                        |     | any other illegal  |         |        |
| -   **Heroin, crack or |     | drug?              |         |        |
|     cocaine,           |     |                    |         |        |
|     methamphetamine**  |     |                    |         |        |
|                        |     |                    |         |        |
| -   **Hallucinogens**  |     |                    |         |        |
|     (drugs that cause  |     |                    |         |        |
|     people to see or   |     |                    |         |        |
|     experience things  |     |                    |         |        |
|     that are not real) |     |                    |         |        |
|     such as LSD        |     |                    |         |        |
|     (sometimes called  |     |                    |         |        |
|     acid), Ecstasy     |     |                    |         |        |
|     (sometimes called  |     |                    |         |        |
|     MDMA), PCP or      |     |                    |         |        |
|     peyote (sometimes  |     |                    |         |        |
|     called angel dust) |     |                    |         |        |
|                        |     |                    |         |        |
| -   **Inhalants or     |     |                    |         |        |
|     sniffed            |     |                    |         |        |
|     substances** such  |     |                    |         |        |
|     as glue, gasoline, |     |                    |         |        |
|     paint thinner,     |     |                    |         |        |
|     cleaning fluid, or |     |                    |         |        |
|     shoe polish (used  |     |                    |         |        |
|     to "feel good" or  |     |                    |         |        |
|     to get high)       |     |                    |         |        |
|                        |     |                    |         |        |
| -   **Prescription     |     |                    |         |        |
|     drugs without a    |     |                    |         |        |
|     doctor's orders,** |     |                    |         |        |
|     just to "feel      |     |                    |         |        |
|     good" or to get    |     |                    |         |        |
|     high               |     |                    |         |        |
+------------------------+-----+--------------------+---------+--------+

**6.** **Think back over your entire lifetime and try to remember
whether you have EVER used any of the following substances. If so, what
was your age the FIRST TIME you used the substance:**

+-------------------------+---+-------------+-------+-------+--------+
|                         |   |             | Check | Fill  | Check  |
|                         |   |             | if    | in    | if     |
|                         |   |             | NEVER | your  | don't  |
|                         |   |             |       | age   | know   |
|                         |   |             |       | when  | or     |
|                         |   |             |       | you   | can't  |
|                         |   |             |       | first | say    |
|                         |   |             |       | used  |        |
|                         |   |             |       | (in   |        |
|                         |   |             |       | y     |        |
|                         |   |             |       | ears) |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Cigarettes:** Include | 6 | Ever smoked |       |       |        |
| menthol and regular     | a | part or all |       |       |        |
| cigarettes and loose    | . | of a        |       |       |        |
| tobacco rolled into     |   | cigarette?  |       |       |        |
| cigarettes              |   |             |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Other tobacco         | 6 | Ever used   |       |       |        |
| products:** Include any | b | any other   |       |       |        |
| tobacco product other   | . | tobacco     |       |       |        |
| than cigarettes such as |   | product?    |       |       |        |
| snuff, chewing tobacco, |   |             |       |       |        |
| and smoking tobacco     |   |             |       |       |        |
| from a pipe             |   |             |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Alcoholic             | 6 | Ever had a  |       |       |        |
| beverages:** Include    | c | drink of an |       |       |        |
| beer, wine, wine        | . | alcoholic   |       |       |        |
| coolers, malt           |   | beverage?   |       |       |        |
| beverages, and liquor   |   | Do NOT      |       |       |        |
|                         |   | include any |       |       |        |
|                         |   | time when   |       |       |        |
|                         |   | you only    |       |       |        |
|                         |   | had a sip   |       |       |        |
|                         |   | or two from |       |       |        |
|                         |   | a drink.    |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Marijuana or          | 6 | Ever used   |       |       |        |
| hashish:** Also known   | d | marijuana   |       |       |        |
| as grass, pot, hash, or | . | or hashish? |       |       |        |
| hash oil                |   |             |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Other illegal         | 6 | Ever used   |       |       |        |
| drugs:** Include        | e | any other   |       |       |        |
| substances like:        | . | illegal     |       |       |        |
|                         |   | drug?       |       |       |        |
| -   **Heroin, crack or  |   |             |       |       |        |
|     cocaine,            |   |             |       |       |        |
|     methamphetamine**   |   |             |       |       |        |
|                         |   |             |       |       |        |
| -   **Hallucinogens**   |   |             |       |       |        |
|     (drugs that cause   |   |             |       |       |        |
|     people to see or    |   |             |       |       |        |
|     experience things   |   |             |       |       |        |
|     that are not real)  |   |             |       |       |        |
|     such as LSD         |   |             |       |       |        |
|     (sometimes called   |   |             |       |       |        |
|     acid), Ecstasy      |   |             |       |       |        |
|     (sometimes called   |   |             |       |       |        |
|     MDMA), PCP or       |   |             |       |       |        |
|     peyote (sometimes   |   |             |       |       |        |
|     called angel dust)  |   |             |       |       |        |
|                         |   |             |       |       |        |
| -   **Inhalants or      |   |             |       |       |        |
|     sniffed             |   |             |       |       |        |
|     substances** such   |   |             |       |       |        |
|     as glue, gasoline,  |   |             |       |       |        |
|     paint thinner,      |   |             |       |       |        |
|     cleaning fluid, or  |   |             |       |       |        |
|     shoe polish (used   |   |             |       |       |        |
|     to "feel good" or   |   |             |       |       |        |
|     to get high)        |   |             |       |       |        |
|                         |   |             |       |       |        |
| -   **Prescription      |   |             |       |       |        |
|     drugs without a     |   |             |       |       |        |
|     doctor's orders,**  |   |             |       |       |        |
|     just to "feel good" |   |             |       |       |        |
|     or to get high      |   |             |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+

7.  **For each of the following five questions below check the box that
    shows how YOU think or feel.**

  ----- ------------------------- ------------ ------------ ------------ -------
                                  Neither      Somewhat     Strongly     Don't
                                  approve nor  disapprove   disapprove   know or
                                  disapprove                             can't
                                                                         say

  7a.   How do *you* feel about                                          
        someone your age smoking                                         
        one or more packs of                                             
        cigarettes a day?                                                

  7b.   How do you think *your                                           
        close friends* would feel                                        
        about YOU smoking one or                                         
        more packs of cigarettes                                         
        a day?                                                           

  7c.   How do *you* feel about                                          
        someone your age trying                                          
        marijuana or hashish once                                        
        or twice?                                                        

  7d.   How do *you* feel about                                          
        someone your age using                                           
        marijuana once a month or                                        
        more?                                                            

  7e.   How do *you* feel about                                          
        someone your age having                                          
        one or two drinks of an                                          
        alcoholic beverage nearly                                        
        every day?                                                       
  ----- ------------------------- ------------ ------------ ------------ -------

**8. For each of the three questions below check one box that shows HOW
MUCH you think people RISK HARMING themselves physically or in other
ways when they do the following things:**

  ----- ------------------------- ------ -------- ---------- ------- -----------
                                  No     Slight   Moderate   Great   Don't know
                                  risk   risk     risk       risk    or can't
                                                                     say

  8a.   When they smoke one or                                       
        more packs of CIGARETTES                                     
        per day?                                                     

  8b.   When they smoke MARIJUANA                                    
        once or twice a week?                                        

  8c.   When they have five or                                       
        more drinks of an                                            
        ALCOHOLIC BEVERAGE once                                      
        or twice a week?                                             
  ----- ------------------------- ------ -------- ---------- ------- -----------

+-----------------------------------+-----------------------------------+
| **This section asks just a few    |                                   |
| additional questions about your   |                                   |
| attitudes and experiences.**      |                                   |
+-----------------------------------+-----------------------------------+
| **9. Would you be more or less    | > More likely                     |
| likely to want to work for an     | >                                 |
| employer that tests its employees | > Less likely                     |
| for drug or alcohol use on a      | >                                 |
| random basis? Would you say more  | > Would make no difference        |
| likely, less likely, or would it  | >                                 |
| make no difference to you? (Check | > Don't know or can't say         |
| one)**                            |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| **10. Now think about the past 12 | > Yes                             |
| months through today. DURING THE  | >                                 |
| PAST 12 MONTHS, have you talked   | > No                              |
| with at least one of your parents | >                                 |
| about the dangers of tobacco,     | > Don't know or can't say         |
| alcohol, or drug use? By PARENTS, |                                   |
| we mean your biological parents,  |                                   |
| adoptive parents, stepparents, or |                                   |
| adult guardians---whether or not  |                                   |
| they live with you.**             |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| **11. During the past 12 months,  | > Yes                             |
| do you recall\                    | >                                 |
| hearing, reading, or watching an  | > No                              |
| advertisement about prevention of | >                                 |
| substance abuse?**                | > Don't know or can't say         |
+-----------------------------------+-----------------------------------+

B-2 Youth Programs Survey Form

**Form Approved**

> **OMB No.: 09300230**

**     Expiration Date: 12/31/2008**

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Youth Programs Survey Form

(Participants ages 12--17)

Use this **Youth Programs Survey Form** for participants in prevention
interventions who are expected to complete survey forms at baseline,
exit, and follow-up periods.

![](media/image1.wmf){width="6.5in" height="2.7777777777777776e-2in"}

Public Burden Statement: An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. The OMB control number
for this project is 0930-0230. Public reporting burden for this
collection of information is estimated to average 1 hour per client per
year, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to SAMHSA
Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville,
Maryland 20857.

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Youth Programs Survey Form

**This survey is voluntary. If you choose to take it, you may skip any
question you don't want to answer.**

This survey asks about your experience and opinion on a number of things
related to alcohol, tobacco, and drug use. Your answers to these
questions will be confidential. That means no one will connect your
answers with your name or any other information about you that can
identify who you are. To help us keep your answers secret, please do not
write your name on this survey form.

The information in this survey will be used to learn more about the
effectiveness of programs in preventing substance abuse and protecting
youth.

This is not a test, so there are no right or wrong answers. Some
questions may ask you to select all of the answers that are relevant,
and others ask you to select a single answer. If the question asks for a
single answer and you don't find an answer that exactly fits, choose one
that comes closest.

**Thank you for agreeing to participate in this survey.**

![](media/image2.wmf){width="6.5in" height="4.1666666666666664e-2in"}

RECORD MANAGEMENT: Your survey administrator will tell you what to fill
in for these administrative questions. You may leave all but **Date
Completed** blank if you are not given any instructions.

![](media/image2.wmf){width="6.5in" height="4.1666666666666664e-2in"}

**Participant ID**

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

**Contract/Grant ID**

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

**Date Completed**

  ----------------- -------- ----------------- -------- -----------------
                    /                          /        

  Month                      Day                        Year
  ----------------- -------- ----------------- -------- -----------------

**Survey Type (Check one)** Baseline Exit First follow-up after exit
Second follow-up

**Study Design Group (Check one)** Intervention Comparison

**Program Name**

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**­­­­­­­­­­Cohort** Number

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **These questions ask for general information about you. Please mark
  the response that best describes you.**

  -----------------------------------------------------------------------

1.  **What is your gender? (Check one)\
    ** Male Female

2.  **Are you Hispanic or Latino? (Check one)**\
    Yes No

3.  **What is your race? (Select one or more)\
    ** White\
    Black or African American\
    American Indian\
    Native Hawaiian or Other Pacific Islander\
    Asian\
    Alaska Native

4.  What is your date of birth?

  --------------------- ------- ---------------- ------- ------------------
                        /                        /       

  Month                         Day                      Year
  --------------------- ------- ---------------- ------- ------------------

  -----------------------------------------------------------------------
  **The next few questions ask about your use of and attitudes toward
  tobacco, alcohol, and other substances.**

  -----------------------------------------------------------------------

**5. Think back over the past 30 days and report how many days, if any,
you used the\
following substances:**

+---------------------+---+----------------------+-------+------------+
|                     |   |                      | Fill  | Check if   |
|                     |   |                      | in    | don't know |
|                     |   |                      | n     | or can't   |
|                     |   |                      | umber | say        |
|                     |   |                      | of    |            |
|                     |   |                      | days\ |            |
|                     |   |                      | (0--  |            |
|                     |   |                      | 30)   |            |
+---------------------+---+----------------------+-------+------------+
| **Cigarettes:**     | 5 | During the past 30   |   --  |            |
| Include menthol and | a | days, on how many    |       |            |
| regular cigarettes  | . | days did you smoke   |   --  |            |
| and loose tobacco   |   | part or all of a     |       |            |
| rolled into         |   | cigarette?           |       |            |
| cigarettes          |   |                      |       |            |
+---------------------+---+----------------------+-------+------------+
| **Other tobacco     | 5 | During the past 30   |   --  |            |
| products**: Include | b | days, on how many    |       |            |
| any tobacco product | . | days did you use     |   --  |            |
| other than          |   | other tobacco        |       |            |
| cigarettes such as  |   | products?            |       |            |
| snuff, chewing      |   |                      |       |            |
| tobacco, and        |   |                      |       |            |
| smoking tobacco     |   |                      |       |            |
| from a pipe         |   |                      |       |            |
+---------------------+---+----------------------+-------+------------+
| **Alcoholic         | 5 | During the past 30   |   --  |            |
| beverages:**        | c | days, on how many    |       |            |
| Include beer, wine, | . | days did you drink   |   --  |            |
| wine coolers, malt  |   | one or more drinks   |       |            |
| beverages, and      |   | of an alcoholic      |       |            |
| liquor              |   | beverage?            |       |            |
+---------------------+---+----------------------+-------+------------+
| **Marijuana or      | 5 | During the past 30   |   --  |            |
| hashish:** Also     | d | days, on how many    |       |            |
| known as grass,     | . | days did you use     |   --  |            |
| pot, hash, or hash  |   | marijuana or         |       |            |
| oil                 |   | hashish?             |       |            |
+---------------------+---+----------------------+-------+------------+
| **Other illegal     | 5 | During the past 30   |   --  |            |
| drugs:** Include    | e | days, on how many    |       |            |
| substances like:    | . | days did you use any |   --  |            |
|                     |   | other illegal drug?  |       |            |
| -   **Heroin, crack |   |                      |       |            |
|     or cocaine,     |   |                      |       |            |
|                     |   |                      |       |            |
|   methamphetamine** |   |                      |       |            |
|                     |   |                      |       |            |
| -                   |   |                      |       |            |
|   **Hallucinogens** |   |                      |       |            |
|     (drugs that     |   |                      |       |            |
|     cause people to |   |                      |       |            |
|     see or          |   |                      |       |            |
|     experience      |   |                      |       |            |
|     things that are |   |                      |       |            |
|     not real) such  |   |                      |       |            |
|     as LSD          |   |                      |       |            |
|     (sometimes      |   |                      |       |            |
|     called acid),   |   |                      |       |            |
|     Ecstasy         |   |                      |       |            |
|     (sometimes      |   |                      |       |            |
|     called MDMA),   |   |                      |       |            |
|     PCP or peyote   |   |                      |       |            |
|     (sometimes      |   |                      |       |            |
|     called angel    |   |                      |       |            |
|     dust)           |   |                      |       |            |
|                     |   |                      |       |            |
| -   **Inhalants or  |   |                      |       |            |
|     sniffed         |   |                      |       |            |
|     substances**    |   |                      |       |            |
|     such as glue,   |   |                      |       |            |
|     gasoline, paint |   |                      |       |            |
|     thinner,        |   |                      |       |            |
|     cleaning fluid, |   |                      |       |            |
|     or shoe polish  |   |                      |       |            |
|     (used to "feel  |   |                      |       |            |
|     good" or to get |   |                      |       |            |
|     high)           |   |                      |       |            |
|                     |   |                      |       |            |
| -   **Prescription  |   |                      |       |            |
|     drugs without a |   |                      |       |            |
|     doctor's        |   |                      |       |            |
|     orders,** just  |   |                      |       |            |
|     to "feel good"  |   |                      |       |            |
|     or to get high  |   |                      |       |            |
+---------------------+---+----------------------+-------+------------+

**6.** **Think back over your entire lifetime and try to remember
whether you have EVER used any of the following substances. If so, what
was your age the FIRST TIME you used the substance:**

+--------------------------+---+-------------+------+---------+------+
|                          |   |             | C    | Fill in | C    |
|                          |   |             | heck | your    | heck |
|                          |   |             | if   | age     | if   |
|                          |   |             | N    | when    | d    |
|                          |   |             | EVER | you     | on't |
|                          |   |             |      | first   | know |
|                          |   |             |      | used    | or   |
|                          |   |             |      | (in     | c    |
|                          |   |             |      | years)  | an't |
|                          |   |             |      |         | say  |
+--------------------------+---+-------------+------+---------+------+
| **Cigarettes:** Include  | 6 | Ever smoked |      |   ----  |      |
| menthol and regular      | a | part or all |      |         |      |
| cigarettes and loose     | . | of a        |      |   ----  |      |
| tobacco rolled into      |   | cigarette?  |      |         |      |
| cigarettes               |   |             |      |         |      |
+--------------------------+---+-------------+------+---------+------+
| **Other tobacco**        | 6 | Ever used   |      |   ----  |      |
| **products:** Include    | b | any other   |      |         |      |
| any tobacco product      | . | tobacco     |      |   ----  |      |
| other than cigarettes    |   | product?    |      |         |      |
| such as snuff, chewing   |   |             |      |         |      |
| tobacco, and smoking     |   |             |      |         |      |
| tobacco from a pipe      |   |             |      |         |      |
+--------------------------+---+-------------+------+---------+------+
| **Alcoholic beverages:** | 6 | Ever had a  |      |   ----  |      |
| Include beer, wine, wine | c | drink of an |      |         |      |
| coolers, malt beverages, | . | alcoholic   |      |   ----  |      |
| and liquor               |   | beverage?   |      |         |      |
|                          |   | Do NOT      |      |         |      |
|                          |   | include any |      |         |      |
|                          |   | time when   |      |         |      |
|                          |   | you only    |      |         |      |
|                          |   | had a sip   |      |         |      |
|                          |   | or two from |      |         |      |
|                          |   | a drink.    |      |         |      |
+--------------------------+---+-------------+------+---------+------+
| **Marijuana or           | 6 | Ever used   |      |   ----  |      |
| hashish:** Also known as | d | marijuana   |      |         |      |
| grass, pot, hash, or     | . | or hashish? |      |   ----  |      |
| hash oil                 |   |             |      |         |      |
+--------------------------+---+-------------+------+---------+------+
| **Other illegal drugs:** | 6 | Ever used   |      |   ----  |      |
| Include substances like: | e | any other   |      |         |      |
|                          | . | illegal     |      |   ----  |      |
| -   **Heroin, crack or   |   | drug?       |      |         |      |
|     cocaine,             |   |             |      |         |      |
|     methamphetamine**    |   |             |      |         |      |
|                          |   |             |      |         |      |
| -   **Hallucinogens**    |   |             |      |         |      |
|     (drugs that cause    |   |             |      |         |      |
|     people to see or     |   |             |      |         |      |
|     experience things    |   |             |      |         |      |
|     that are not real)   |   |             |      |         |      |
|     such as LSD          |   |             |      |         |      |
|     (sometimes called    |   |             |      |         |      |
|     acid), Ecstasy       |   |             |      |         |      |
|     (sometimes called    |   |             |      |         |      |
|     MDMA), PCP or peyote |   |             |      |         |      |
|     (sometimes called    |   |             |      |         |      |
|     angel dust)          |   |             |      |         |      |
|                          |   |             |      |         |      |
| -   **Inhalants or       |   |             |      |         |      |
|     sniffed substances** |   |             |      |         |      |
|     such as glue,        |   |             |      |         |      |
|     gasoline, paint      |   |             |      |         |      |
|     thinner, cleaning    |   |             |      |         |      |
|     fluid, or shoe       |   |             |      |         |      |
|     polish (used to      |   |             |      |         |      |
|     "feel good" or to    |   |             |      |         |      |
|     get high)            |   |             |      |         |      |
|                          |   |             |      |         |      |
| -   **Prescription drugs |   |             |      |         |      |
|     without a doctor's   |   |             |      |         |      |
|     orders,** just to    |   |             |      |         |      |
|     "feel good" or to    |   |             |      |         |      |
|     get high             |   |             |      |         |      |
+--------------------------+---+-------------+------+---------+------+

7.  **For each of the following five questions below check the box that
    shows how YOU think or feel.**

  ----- ---------------------------- ------------ ------------ ------------ -------
                                     Neither      Somewhat     Strongly     Don't
                                     approve nor  disapprove   disapprove   know or
                                     disapprove                             can't
                                                                            say

  7a.   How do *you* feel about                                             
        someone your age smoking one                                        
        or more packs of cigarettes                                         
        a day?                                                              

  7b.   How do you think *your close                                        
        friends* would feel about                                           
        YOU smoking one or more                                             
        packs of cigarettes a day?                                          

  7c.   How do *you* feel about                                             
        someone your age trying                                             
        marijuana or hashish once or                                        
        twice?                                                              

  7d.   How do *you* feel about                                             
        someone your age using                                              
        marijuana once a month or                                           
        more?                                                               

  7e.   How do *you* feel about                                             
        someone your age having one                                         
        or two drinks of an                                                 
        alcoholic beverage nearly                                           
        every day?                                                          
  ----- ---------------------------- ------------ ------------ ------------ -------

**8. For each of the three questions below check one box that shows HOW
MUCH you think\
people RISK HARMING themselves physically or in other ways when they do
the following**

**things:**

  ----- ----------------------- ------ -------- ---------- -------- ----------
                                No     Slight   Moderate   Great    Don't know
                                risk   risk     risk       risk     or can't
                                                                    say

  8a.   When they smoke one or                                      
        more packs of                                               
        CIGARETTES per day?                                         

  8b.   When they smoke                                             
        MARIJUANA once or twice                                     
        a week?                                                     

  8c.   When they have five or                                      
        more drinks of an                                           
        ALCOHOLIC BEVERAGE once                                     
        or twice a week?                                            
  ----- ----------------------- ------ -------- ---------- -------- ----------

  -----------------------------------------------------------------------
  **This section asks just a few additional questions about your
  attitudes and experiences.**

  -----------------------------------------------------------------------

+-----------------------------------+----------------------------------+
| **9. Would you be more or less    | > More likely                    |
| likely to want to work for an     | >                                |
| employer that tests its employees | > Less likely                    |
| for drug or alcohol use on a      | >                                |
| random basis? Would you say more  | > Would make no difference       |
| likely, less likely, or would it  | >                                |
| make no difference to you? (Check | > Don't know or can't say        |
| one)**                            |                                  |
+-----------------------------------+----------------------------------+

+-----------------------------------+----------------------------------+
| **10. DURING THE PAST 12 MONTHS,  | > Yes                            |
| have you driven a vehicle while   | >                                |
| you were under the influence of   | > No                             |
| alcohol?**                        | >                                |
|                                   | > Don't know or can't say        |
+-----------------------------------+----------------------------------+

+---+-----------------------------------------+-------------------------+
|   | **11. Now think about the past 12       | Yes                     |
|   | months through today. DURING THE PAST   |                         |
|   | 12 MONTHS, have you talked with at      | No                      |
|   | least one of your parents about the     |                         |
|   | dangers of tobacco, alcohol, or drug    | Don't know or can't say |
|   | use? By PARENTS, we mean your           |                         |
|   | biological parents, adoptive parents,   |                         |
|   | stepparents, or adult                   |                         |
|   | guardians---whether or not they live    |                         |
|   | with you.**                             |                         |
+---+-----------------------------------------+-------------------------+
|   |                                         |                         |
+---+-----------------------------------------+-------------------------+
| > |                                         | Yes                     |
|   |                                         |                         |
| * |                                         | No                      |
| * |                                         |                         |
| 1 |                                         | Don't know or can't say |
| 2 |                                         |                         |
| . |                                         |                         |
| > |                                         |                         |
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| > |                                         |                         |
|   |                                         |                         |
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|   |                                         |                         |
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|   |                                         |                         |
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| u |                                         |                         |
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| s |                                         |                         |
| e |                                         |                         |
| ? |                                         |                         |
| * |                                         |                         |
| * |                                         |                         |
+---+-----------------------------------------+-------------------------+
|   |                                         |                         |
+---+-----------------------------------------+-------------------------+

B-3 Adult Community Survey Form

**Form Approved**

> **OMB No.: 09300230**

**     Expiration Date:  12/31/2008**

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Adult Community Survey Form

(Adults ages 18 and older)

Use this **Adult Community Survey Form** for surveys of communities in
which data may be collected at a single point in time or at multiple
time points, each time using different samples of individuals rather
than a matched pretest/posttest design.

![](media/image3.wmf){width="6.0in" height="2.7777777777777776e-2in"}

Public Burden Statement: An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. The OMB control number
for this project is 0930-0230. Public reporting burden for this
collection of information is estimated to average 1 hour per client per
year, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to SAMHSA
Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville,
Maryland 20857.

**Center for Substance Abuse Prevention\
National Outcome Measures**

Adult Community Survey Form

**This survey is voluntary. If you choose to take it, you may skip any
question you don't want to answer.**

This survey asks about your experience and opinion on a number of topics
related to alcohol, tobacco, and drug use. Your answers to these
questions will be confidential. That means no one will connect your
answers with your name or other identifying information. To help us keep
your answers confidential, please do not write your name on this survey
form.

The information in this survey will be used to learn more about the
effectiveness of programs in preventing substance abuse.

This is not a test, so there are no right or wrong answers. Some
questions may ask you to select all of the answers that are relevant,
and others ask you to select a single answer. If the question asks for a
single answer and you don't find an answer that exactly fits, choose one
that comes closest.

**Thank you for agreeing to participate in this survey.**

![](media/image2.wmf){width="6.0in" height="4.1666666666666664e-2in"}

RECORD MANAGEMENT: Your survey administrator will tell you what to fill
in for these administrative questions. You may leave all but **Date
Completed** blank if you are not given any instructions.

![](media/image2.wmf){width="6.0in" height="4.1666666666666664e-2in"}

**Participant ID**

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

**Contract/Grant ID**

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

**Date Completed**

  ----------------- -------- ----------------- -------- -----------------
                    /                          /        

  Month                      Day                        Year
  ----------------- -------- ----------------- -------- -----------------

Program Name

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**Cohort** Number

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **These questions ask for general information about you. Please mark
  the response that best describes you.**

  -----------------------------------------------------------------------

1.  **What is your gender? (Check one)\
    ** Male Female

2.  **Are you Hispanic or Latino? (Check one)**\
    Yes No

3.  **What is your race? (Select one or more)\
    ** White\
    Black or African American\
    American Indian\
    Native Hawaiian or Other Pacific Islander\
    Asian\
    Alaska Native

4.  What is your date of birth?

  --------------------- ------- ---------------- ------- ------------------
                        /                        /       

  Month                         Day                      Year
  --------------------- ------- ---------------- ------- ------------------

  -----------------------------------------------------------------------
  **The next few questions ask about your use of and attitudes toward
  tobacco,\
  alcohol, and other substances.**

  -----------------------------------------------------------------------

**5. Think back over the past 30 days and report how many days, if any,
you used the\
following substances:**

+-------------------------+----+-------------------+---------+-------+
|                         |    |                   | Fill in | Check |
|                         |    |                   | number  | if    |
|                         |    |                   | of      | don't |
|                         |    |                   | days\   | know  |
|                         |    |                   | (0--30) | or    |
|                         |    |                   |         | can't |
|                         |    |                   |         | say   |
+-------------------------+----+-------------------+---------+-------+
| **Cigarettes:** Include | 5  | During the past   |         |       |
| menthol and regular     | a. | 30 days, on how   |         |       |
| cigarettes and loose    |    | many days did you |         |       |
| tobacco rolled into     |    | smoke part or all |         |       |
| cigarettes              |    | of a cigarette?   |         |       |
+-------------------------+----+-------------------+---------+-------+
| **Other tobacco         | 5  | During the past   |         |       |
| products:** Include any | b. | 30 days, on how   |         |       |
| tobacco product other   |    | many days did you |         |       |
| than cigarettes such as |    | use other tobacco |         |       |
| snuff, chewing tobacco, |    | products?         |         |       |
| and smoking tobacco     |    |                   |         |       |
| from a pipe             |    |                   |         |       |
+-------------------------+----+-------------------+---------+-------+
| **Alcoholic             | 5  | During the past   |         |       |
| beverages:** Include    | c. | 30 days, on how   |         |       |
| beer, wine, wine        |    | many days did you |         |       |
| coolers, malt           |    | drink one or more |         |       |
| beverages, and liquor   |    | drinks of an      |         |       |
|                         |    | alcoholic         |         |       |
|                         |    | beverage?         |         |       |
+-------------------------+----+-------------------+---------+-------+
| **Marijuana or          | 5  | During the past   |         |       |
| hashish:** Also known   | d. | 30 days, on how   |         |       |
| as grass, pot, hash, or |    | many days did you |         |       |
| hash oil                |    | use marijuana or  |         |       |
|                         |    | hashish?          |         |       |
+-------------------------+----+-------------------+---------+-------+
| **Other illegal         | 5  | During the past   |         |       |
| drugs:** Include        | e. | 30 days, on how   |         |       |
| substances like:        |    | many days did you |         |       |
|                         |    | use any other     |         |       |
| -   **Heroin, crack or  |    | illegal drug?     |         |       |
|     cocaine,            |    |                   |         |       |
|     methamphetamine**   |    |                   |         |       |
|                         |    |                   |         |       |
| -   **Hallucinogens**   |    |                   |         |       |
|     (drugs that cause   |    |                   |         |       |
|     people to see or    |    |                   |         |       |
|     experience things   |    |                   |         |       |
|     that are not real)  |    |                   |         |       |
|     such as LSD         |    |                   |         |       |
|     (sometimes called   |    |                   |         |       |
|     acid), Ecstasy      |    |                   |         |       |
|     (sometimes called   |    |                   |         |       |
|     MDMA), PCP or       |    |                   |         |       |
|     peyote (sometimes   |    |                   |         |       |
|     called angel dust)  |    |                   |         |       |
|                         |    |                   |         |       |
| -   **Inhalants or      |    |                   |         |       |
|     sniffed             |    |                   |         |       |
|     substances** such   |    |                   |         |       |
|     as glue, gasoline,  |    |                   |         |       |
|     paint thinner,      |    |                   |         |       |
|     cleaning fluid, or  |    |                   |         |       |
|     shoe polish (used   |    |                   |         |       |
|     to "feel good" or   |    |                   |         |       |
|     to get high)        |    |                   |         |       |
|                         |    |                   |         |       |
| -   **Prescription      |    |                   |         |       |
|     drugs without a     |    |                   |         |       |
|     doctor's orders,**  |    |                   |         |       |
|     just to "feel good" |    |                   |         |       |
|     or to get high      |    |                   |         |       |
+-------------------------+----+-------------------+---------+-------+

**6. Think back over your entire lifetime and try to remember whether
you have EVER used any of the following substances. If so, what was your
age the FIRST TIME you used the substance:**

+--------------------------+---+------------+-------+-------+--------+
|                          |   |            | Check | Fill  | Check  |
|                          |   |            | if    | in    | if     |
|                          |   |            | NEVER | your  | don't  |
|                          |   |            |       | age   | know   |
|                          |   |            |       | when  | or     |
|                          |   |            |       | you   | can't  |
|                          |   |            |       | first | say    |
|                          |   |            |       | used  |        |
|                          |   |            |       | (in   |        |
|                          |   |            |       | y     |        |
|                          |   |            |       | ears) |        |
+--------------------------+---+------------+-------+-------+--------+
| **Cigarettes:** Include  | 6 | Ever       |       |       |        |
| menthol and regular      | a | smoked     |       |       |        |
| cigarettes and loose     | . | part or    |       |       |        |
| tobacco rolled into      |   | all of a   |       |       |        |
| cigarettes               |   | cigarette? |       |       |        |
+--------------------------+---+------------+-------+-------+--------+
| **Other tobacco          | 6 | Ever used  |       |       |        |
| products:** Include any  | b | any other  |       |       |        |
| tobacco product other    | . | tobacco    |       |       |        |
| than cigarettes such as  |   | product?   |       |       |        |
| snuff, chewing tobacco,  |   |            |       |       |        |
| and smoking tobacco from |   |            |       |       |        |
| a pipe                   |   |            |       |       |        |
+--------------------------+---+------------+-------+-------+--------+
| **Alcoholic beverages:** | 6 | Ever had a |       |       |        |
| Include beer, wine, wine | c | drink of   |       |       |        |
| coolers, malt beverages, | . | an         |       |       |        |
| and liquor               |   | alcoholic  |       |       |        |
|                          |   | beverage?  |       |       |        |
|                          |   | Do NOT     |       |       |        |
|                          |   | include    |       |       |        |
|                          |   | any time   |       |       |        |
|                          |   | when you   |       |       |        |
|                          |   | only had a |       |       |        |
|                          |   | sip or two |       |       |        |
|                          |   | from a     |       |       |        |
|                          |   | drink.     |       |       |        |
+--------------------------+---+------------+-------+-------+--------+
| **Marijuana or           | 6 | Ever used  |       |       |        |
| hashish:** Also known as | d | marijuana  |       |       |        |
| grass, pot, hash, or     | . | or         |       |       |        |
| hash oil                 |   | hashish?   |       |       |        |
+--------------------------+---+------------+-------+-------+--------+
| **Other illegal drugs:** | 6 | Ever used  |       |       |        |
| Include substances like: | e | any other  |       |       |        |
|                          | . | illegal    |       |       |        |
| -   **Heroin, crack or   |   | drug?      |       |       |        |
|     cocaine,             |   |            |       |       |        |
|     methamphetamine**    |   |            |       |       |        |
|                          |   |            |       |       |        |
| -   **Hallucinogens**    |   |            |       |       |        |
|     (drugs that cause    |   |            |       |       |        |
|     people to see or     |   |            |       |       |        |
|     experience things    |   |            |       |       |        |
|     that are not real)   |   |            |       |       |        |
|     such as LSD          |   |            |       |       |        |
|     (sometimes called    |   |            |       |       |        |
|     acid), Ecstasy       |   |            |       |       |        |
|     (sometimes called    |   |            |       |       |        |
|     MDMA), PCP or peyote |   |            |       |       |        |
|     (sometimes called    |   |            |       |       |        |
|     angel dust)          |   |            |       |       |        |
|                          |   |            |       |       |        |
| -   **Inhalants or       |   |            |       |       |        |
|     sniffed substances** |   |            |       |       |        |
|     such as glue,        |   |            |       |       |        |
|     gasoline, paint      |   |            |       |       |        |
|     thinner, cleaning    |   |            |       |       |        |
|     fluid, or shoe       |   |            |       |       |        |
|     polish (used to      |   |            |       |       |        |
|     "feel good" or to    |   |            |       |       |        |
|     get high)            |   |            |       |       |        |
|                          |   |            |       |       |        |
| -   **Prescription drugs |   |            |       |       |        |
|     without a doctor's   |   |            |       |       |        |
|     orders,** just to    |   |            |       |       |        |
|     "feel good" or to    |   |            |       |       |        |
|     get high             |   |            |       |       |        |
+--------------------------+---+------------+-------+-------+--------+

**7. For each of the three questions below check one box that shows HOW
MUCH you think\
people RISK HARMING themselves physically or in other ways when they
engage in the**

**following behaviors:**

  ----- --------------------------- ------ -------- ---------- ------- ----------
                                    No     Slight   Moderate   Great   Don't know
                                    risk   risk     risk       risk    or can't
                                                                       say

  7a.   When they smoke one or more                                    
        packs of CIGARETTES per                                        
        day?                                                           

  7b.   When they smoke MARIJUANA                                      
        once or twice a week?                                          

  7c.   When they have five or more                                    
        drinks of an ALCOHOLIC                                         
        BEVERAGE once or twice a                                       
        week?                                                          
  ----- --------------------------- ------ -------- ---------- ------- ----------

  -----------------------------------------------------------------------
  **This section asks just a few additional questions about your
  attitudes and experiences.**

  -----------------------------------------------------------------------

+-------------------------+----------------------------------+---------+
| **8. Would you be more  | More likely                      |         |
| or less likely to want  |                                  |         |
| to work for an employer | Less likely                      |         |
| that tests its          |                                  |         |
| employees for drug or   | Would make no difference         |         |
| alcohol use on a random |                                  |         |
| basis? Would you say    | Don't know or can't say          |         |
| more likely, less       |                                  |         |
| likely, or would it     |                                  |         |
| make no difference to   |                                  |         |
| you? (Check one)**      |                                  |         |
+-------------------------+----------------------------------+---------+

+-----------------------------------+-----------------------------------+
| **9. Now think about the past 12  | Don't have any children           |
| months through today. DURING THE  |                                   |
| PAST 12 MONTHS, how many times    | 0 times                           |
| have you talked with your child   |                                   |
| about the dangers or problems     | 1 to 2 times                      |
| associated with the use of        |                                   |
| tobacco, alcohol, or drugs?**     | A few times                       |
|                                   |                                   |
|                                   | Many times                        |
|                                   |                                   |
|                                   | Don't know or can't say           |
+-----------------------------------+-----------------------------------+

B-4 Adult Programs Survey Form

**Form Approved**

> **OMB No.: 09300230**

**     Expiration Date:  12/31/2008**

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Adult Programs Survey Form

(Adult participants ages 18 and older)

Use this **Adult Programs Survey Form** for participants in prevention
interventions who are expected to complete survey forms at baseline,
exit, and follow-up periods.

![](media/image3.wmf){width="6.5in" height="2.7777777777777776e-2in"}

Public Burden Statement: An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. The OMB control number
for this project is 0930-0230. Public reporting burden for this
collection of information is estimated to average 1 hour per client per
year, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to SAMHSA
Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville,
Maryland 20857.

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Adult Programs Survey Form

**This survey is voluntary. If you choose to take it, you may skip any
question you don't want to answer.**

This survey asks about your experience and opinion on a number of topics
related to alcohol, tobacco, and drug use. Your answers to these
questions will be confidential. That means no one will connect your
answers with your name or other identifying information. To help us keep
your answers confidential, please do not write your name on this survey
form.

The information in this survey will be used to learn more about the
effectiveness of programs in preventing substance abuse.

This is not a test, so there are no right or wrong answers. Some
questions may ask you to select all of the answers that are relevant,
and others ask you to select a single answer. If the question asks for a
single answer and you don't find an answer that exactly fits, choose one
that comes closest.

**Thank you for agreeing to participate in this survey.**

![](media/image2.wmf){width="6.0in" height="4.1666666666666664e-2in"}

RECORD MANAGEMENT: Your survey administrator will tell you what to fill
in for these administrative questions. You may leave all but **Date
Completed** blank if you are not given any instructions.

![](media/image2.wmf){width="6.0in" height="4.1666666666666664e-2in"}

**Participant ID**

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

**Contract/Grant ID**

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

**Date Completed**

  ----------------- -------- ----------------- -------- -----------------
                    /                          /        

  Month                      Day                        Year
  ----------------- -------- ----------------- -------- -----------------

**Survey Type (Check one)** Baseline Exit First follow-up after exit
Second follow-up

**Study Design Group (Check one)** Intervention Comparison

**Program Name**

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**­­­­­­­­­­Cohort Number**

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **These questions ask for general information about you. Please mark
  the response that best describes you.**

  -----------------------------------------------------------------------

1.  **What is your gender? (Check one)\
    ** Male Female

2.  **Are you Hispanic or Latino? (Check one)**\
    Yes No

3.  **What is your race? (Select one or more)\
    ** White\
    Black or African American\
    American Indian\
    Native Hawaiian or Other Pacific Islander\
    Asian\
    Alaska Native

4.  What is your date of birth?

  --------------------- ------- ---------------- ------- ------------------
                        /                        /       

  Month                         Day                      Year
  --------------------- ------- ---------------- ------- ------------------

  -----------------------------------------------------------------------
  **The next few questions ask about your use of and attitudes toward
  tobacco, alcohol, and other substances.**

  -----------------------------------------------------------------------

**5. Think back over the past 30 days and report how many days, if any,
you used the\
following substances:**

+---------------------+----+-------------------------+------+---------+
|                     |    |                         | Fill | Check   |
|                     |    |                         | in   | if      |
|                     |    |                         | nu   | don't   |
|                     |    |                         | mber | know or |
|                     |    |                         | of   | can't   |
|                     |    |                         | days | say     |
|                     |    |                         | (0-  |         |
|                     |    |                         | -30) |         |
+---------------------+----+-------------------------+------+---------+
| **Cigarettes:**     | 5  | During the past 30      |   -- |         |
| Include menthol and | a. | days, on how many days  |      |         |
| regular cigarettes  |    | did you smoke part or   |   -- |         |
| and loose tobacco   |    | all of a cigarette?     |      |         |
| rolled into         |    |                         |      |         |
| cigarettes          |    |                         |      |         |
+---------------------+----+-------------------------+------+---------+
| **Other tobacco     | 5  | During the past 30      |   -- |         |
| products**: Include | b. | days, on how many days  |      |         |
| any tobacco product |    | did you use other       |   -- |         |
| other than          |    | tobacco products?       |      |         |
| cigarettes such as  |    |                         |      |         |
| snuff, chewing      |    |                         |      |         |
| tobacco, and        |    |                         |      |         |
| smoking tobacco     |    |                         |      |         |
| from a pipe         |    |                         |      |         |
+---------------------+----+-------------------------+------+---------+
| **Alcoholic         | 5  | During the past 30      |   -- |         |
| beverages:**        | c. | days, on how many days  |      |         |
| Include beer, wine, |    | did you drink one or    |   -- |         |
| wine coolers, malt  |    | more drinks of an       |      |         |
| beverages, and      |    | alcoholic beverage?     |      |         |
| liquor              |    |                         |      |         |
+---------------------+----+-------------------------+------+---------+
| **Marijuana or      | 5  | During the past 30      |   -- |         |
| hashish:** Also     | d. | days, on how many days  |      |         |
| known as grass,     |    | did you use marijuana   |   -- |         |
| pot, hash, or hash  |    | or hashish?             |      |         |
| oil                 |    |                         |      |         |
+---------------------+----+-------------------------+------+---------+
| **Other illegal     | 5  | During the past 30      |   -- |         |
| drugs:** Include    | e. | days, on how many days  |      |         |
| substances like:    |    | did you use any other   |   -- |         |
|                     |    | illegal drug?           |      |         |
| -   **Heroin, crack |    |                         |      |         |
|     or cocaine,     |    |                         |      |         |
|                     |    |                         |      |         |
|   methamphetamine** |    |                         |      |         |
|                     |    |                         |      |         |
| -                   |    |                         |      |         |
|   **Hallucinogens** |    |                         |      |         |
|     (drugs that     |    |                         |      |         |
|     cause people to |    |                         |      |         |
|     see or          |    |                         |      |         |
|     experience      |    |                         |      |         |
|     things that are |    |                         |      |         |
|     not real) such  |    |                         |      |         |
|     as LSD          |    |                         |      |         |
|     (sometimes      |    |                         |      |         |
|     called acid),   |    |                         |      |         |
|     Ecstasy         |    |                         |      |         |
|     (sometimes      |    |                         |      |         |
|     called MDMA),   |    |                         |      |         |
|     PCP or peyote   |    |                         |      |         |
|     (sometimes      |    |                         |      |         |
|     called angel    |    |                         |      |         |
|     dust)           |    |                         |      |         |
|                     |    |                         |      |         |
| -   **Inhalants or  |    |                         |      |         |
|     sniffed         |    |                         |      |         |
|     substances**    |    |                         |      |         |
|     such as glue,   |    |                         |      |         |
|     gasoline, paint |    |                         |      |         |
|     thinner,        |    |                         |      |         |
|     cleaning fluid, |    |                         |      |         |
|     or shoe polish  |    |                         |      |         |
|     (used to "feel  |    |                         |      |         |
|     good" or to get |    |                         |      |         |
|     high)           |    |                         |      |         |
|                     |    |                         |      |         |
| -   **Prescription  |    |                         |      |         |
|     drugs without a |    |                         |      |         |
|     doctor's        |    |                         |      |         |
|     orders,** just  |    |                         |      |         |
|     to "feel good"  |    |                         |      |         |
|     or to get high  |    |                         |      |         |
+---------------------+----+-------------------------+------+---------+

**6.** **Think back over your entire lifetime and try to remember
whether you have EVER used any of the following substances. If so, what
was your age the FIRST TIME you used the substance:**

+-------------------------+---+--------------+------+---------+------+
|                         |   |              | C    | Fill in | C    |
|                         |   |              | heck | your    | heck |
|                         |   |              | if   | age     | if   |
|                         |   |              | N    | when    | d    |
|                         |   |              | EVER | you     | on't |
|                         |   |              |      | first   | know |
|                         |   |              |      | used    | or   |
|                         |   |              |      | (in     | c    |
|                         |   |              |      | years ) | an't |
|                         |   |              |      |         | say  |
+-------------------------+---+--------------+------+---------+------+
| **Cigarettes:** Include | 6 | Ever smoked  |      |   ----  |      |
| menthol and regular     | a | part or all  |      |         |      |
| cigarettes and loose    | . | of a         |      |   ----  |      |
| tobacco rolled into     |   | cigarette?   |      |         |      |
| cigarettes              |   |              |      |         |      |
+-------------------------+---+--------------+------+---------+------+
| **Other tobacco**       | 6 | Ever used    |      |   ----  |      |
| **products:** Include   | b | any other    |      |         |      |
| any tobacco product     | . | tobacco      |      |   ----  |      |
| other than cigarettes   |   | product?     |      |         |      |
| such as snuff, chewing  |   |              |      |         |      |
| tobacco, and smoking    |   |              |      |         |      |
| tobacco from a pipe     |   |              |      |         |      |
+-------------------------+---+--------------+------+---------+------+
| **Alcoholic             | 6 | Ever had a   |      |   ----  |      |
| beverages:** Include    | c | drink of an  |      |         |      |
| beer, wine, wine        | . | alcoholic    |      |   ----  |      |
| coolers, malt           |   | beverage? Do |      |         |      |
| beverages, and liquor   |   | NOT include  |      |         |      |
|                         |   | any time     |      |         |      |
|                         |   | when you     |      |         |      |
|                         |   | only had a   |      |         |      |
|                         |   | sip or two   |      |         |      |
|                         |   | from a       |      |         |      |
|                         |   | drink.       |      |         |      |
+-------------------------+---+--------------+------+---------+------+
| **Marijuana or          | 6 | Ever used    |      |   ----  |      |
| hashish:** Also known   | d | marijuana or |      |         |      |
| as grass, pot, hash, or | . | hashish?     |      |   ----  |      |
| hash oil                |   |              |      |         |      |
+-------------------------+---+--------------+------+---------+------+
| **Other illegal         | 6 | Ever used    |      |   ----  |      |
| drugs:** Include        | e | any other    |      |         |      |
| substances like:        | . | illegal      |      |   ----  |      |
|                         |   | drug?        |      |         |      |
| -   **Heroin, crack or  |   |              |      |         |      |
|     cocaine,            |   |              |      |         |      |
|     methamphetamine**   |   |              |      |         |      |
|                         |   |              |      |         |      |
| -   **Hallucinogens**   |   |              |      |         |      |
|     (drugs that cause   |   |              |      |         |      |
|     people to see or    |   |              |      |         |      |
|     experience things   |   |              |      |         |      |
|     that are not real)  |   |              |      |         |      |
|     such as LSD         |   |              |      |         |      |
|     (sometimes called   |   |              |      |         |      |
|     acid), Ecstasy      |   |              |      |         |      |
|     (sometimes called   |   |              |      |         |      |
|     MDMA), PCP or       |   |              |      |         |      |
|     peyote (sometimes   |   |              |      |         |      |
|     called angel dust)  |   |              |      |         |      |
|                         |   |              |      |         |      |
| -   **Inhalants or      |   |              |      |         |      |
|     sniffed             |   |              |      |         |      |
|     substances** such   |   |              |      |         |      |
|     as glue, gasoline,  |   |              |      |         |      |
|     paint thinner,      |   |              |      |         |      |
|     cleaning fluid, or  |   |              |      |         |      |
|     shoe polish (used   |   |              |      |         |      |
|     to "feel good" or   |   |              |      |         |      |
|     to get high)        |   |              |      |         |      |
|                         |   |              |      |         |      |
| -   **Prescription      |   |              |      |         |      |
|     drugs without a     |   |              |      |         |      |
|     doctor's orders,**  |   |              |      |         |      |
|     just to "feel good" |   |              |      |         |      |
|     or to get high      |   |              |      |         |      |
+-------------------------+---+--------------+------+---------+------+

7.  **For each of the three questions below check one box that shows HOW
    MUCH you think people RISK HARMING themselves physically or in other
    ways when they engage in the following behaviors:**

  ------ --------------------- ------ -------- ---------- --------- ------------
                               No     Slight   Moderate   Great     Don't know
                               risk   risk     risk       risk      or can't say

  7a.    When they smoke one                                        
         or more packs of                                           
         CIGARETTES per day?                                        

  7b.    When they smoke                                            
         MARIJUANA once or                                          
         twice a week?                                              

  7c.    When they have five                                        
         or more drinks of an                                       
         ALCOHOLIC BEVERAGE                                         
         once or twice a week?                                      
  ------ --------------------- ------ -------- ---------- --------- ------------

  -----------------------------------------------------------------------
  **This section asks just a few additional questions about your
  attitudes and experiences.**

  -----------------------------------------------------------------------

+--------------------------------------+-------------------------+-----+
| **8. Would you be more or less       | More likely             |     |
| likely to want to work for an        |                         |     |
| employer that tests its employees    | Less likely             |     |
| for drug or alcohol use on a random  |                         |     |
| basis? Would you say more likely,    | Would make no           |     |
| less likely, or would it make no     | difference              |     |
| difference to you? (Check one)**     |                         |     |
|                                      | Don't know or can't say |     |
+--------------------------------------+-------------------------+-----+
| **9. DURING THE PAST 12 MONTHS, have | Yes                     |     |
| you\                                 |                         |     |
| driven a vehicle while you were      | No                      |     |
| under the influence of alcohol?**    |                         |     |
|                                      | Don't know or can't say |     |
+--------------------------------------+-------------------------+-----+