**Form Approved**

**OMB No. 0930-0208**

**Expiration Date1/31/2007**

**CSAP GPRA Participant Outcome**

**Measures for Discretionary Programs**

**ADULTS**

Public reporting burden for this collection of information is estimated
to average 20 minutes per response if all items are asked of a
participant; to the extent that providers already obtain much of this
information as part of their ongoing participant intake or follow-up,
less time will be required. Send comments regarding this burden estimate
or any other aspect of this collection of information to SAMHSA Reports
Clearance Officer, Room 16-105, 5600 Fishers Lane, Rockville, MD 20857.
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 control number for this project is
0930-0208.

**9/03**

**RECORD MANAGEMENT**

**Participant ID
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Contract/Grant ID
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Grant Year \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

> **Year**

**Interview Date \|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Interview Type**

> **1. Pre-Test 2. Post-Test 3. 6-Month Follow-up**

**A. DEMOGRAPHICS (QUESTIONS 1-4 ASKED ONLY AT BASELINE)**

**1. Gender**

> \_ **Male**
>
> **\_ Female**

**2. Are you Hispanic or Latino?**

> **\_ Yes \_ No**

**3. What is your race? (Select one or more)**

> \_ **Black or African American \_ Alaska Native**
>
> **\_ Asian \_ White**
>
> **\_ American Indian**
>
> **\_ Native Hawaiian or Other  Pacific Islander**

**4. What is your date of birth? \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

> **Month / Day / Year**

**B. DRUG AND ALCOHOL USE**

+---------------------------------------------------------------------+---+
| 31764. What is your best estimate of the number of days you used    |   |
|        chewing tobacco during the past 30 days?                     |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 1.  What is your best estimate of the number of days you smoked all |   |
|     or part of a cigarette during the past 30 days?                 |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 3.  What is your best estimate of the number of days you drank      |   |
|     alcohol during the past 30 days?                                |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 4.  What is your best estimate of the number of days you used       |   |
|     marijuana or hashish during the past 30 days?                   |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 5.  What is your best estimate of the number of days you used       |   |
|     cocaine during the past 30 days?                                |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 6.  What is your best estimate of the number of days you used       |   |
|     "crack" during the past 30 days?                                |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 7.  What is your best estimate of the number of days you used any   |   |
|     inhalant for kicks or to get high during the past 30 days?      |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 8.  What is your best estimate of the number of days you used       |   |
|     heroin during the past 30 days?                                 |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+
| 9.  What is your best estimate of the number of days you used       |   |
|     hallucinogens during the past 30 days?                          |   |
|                                                                     |   |
| > 0 0 days                                                          |   |
| >                                                                   |   |
| > 1 1 or 2 days                                                     |   |
| >                                                                   |   |
| > 2 3 to 5 days                                                     |   |
| >                                                                   |   |
| > 3 6 to 9 days                                                     |   |
| >                                                                   |   |
| > 4 10 to 19 days                                                   |   |
| >                                                                   |   |
| > 5 20 to 29 days                                                   |   |
| >                                                                   |   |
| > 6 all 30 days                                                     |   |
+---------------------------------------------------------------------+---+

**10. How old were you the [first time]{.underline} you smoked part or
all of a cigarette?**

> years old If never smoked part or all of a cigarette please mark the
> box. 

**11. Think about the [first time]{.underline} you had a drink of an
alcoholic beverage. How old were you the first time you had a drink of
an alcoholic beverage? Please do not include any time when you only had
a sip or two from a drink.**

> years old If never had a drink of an alcoholic beverage please mark
> the box. 

**12. How old were you the [first time]{.underline} you used marijuana
or hashish?**

> years old If never used marijuana or hashish please mark the box. 

**13. How old were you the [first time]{.underline} you used any other
illegal drugs?**

> years old If never used any illegal drugs please mark the box. 

**D. EDUCATION, EMPLOYMENT, AND INCOME**

**1. What is the highest level of education you have finished, whether
or not you received a degree? \[01=1st grade, 12=12th grade, 13=college
freshman, 16=college completion\]**

**\|\_\_\_\_\|\_\_\_\_\| level in years**

> **1a. If less than 12 years of education, do you have a GED (General
> Equivalency Diploma)?**
>
> \_ **Yes** \_ **No**

**G. ATTITUDES AND BELIEFS**

**1. How much do people risk harming themselves physically and in other
ways when they smoke one or more packs of cigarettes per day?**

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

**2. How much do people risk harming themselves physically and in other
ways when they smoke marijuana once a month?**

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

3.  How much do people risk harming themselves physically and in other
    ways when they:

a\. Have four or five drinks of an alcoholic beverage nearly every day?

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

**b. Have five or more drinks of an alcoholic beverage once or twice a
week?**

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

4.  How do you feel about adults smoking one or more packs of cigarettes
    per day?

> \_ **Neither approve nor disapprove**

\_ **Somewhat disapprove**

\_ **Strongly disapprove**

5.  How do you feel about adults trying marijuana or hashish once or
    twice?

> \_ **Neither approve nor disapprove**

\_ **Somewhat disapprove**

\_ **Strongly disapprove**

6.  How do you feel about adults having one or two drinks of an
    alcoholic beverage nearly every day?

> \_ **Neither approve nor disapprove**

\_ **Somewhat disapprove**

\_ **Strongly disapprove**

7.  How do you feel about adults driving a car after having one or two
    drinks of an alcoholic beverage?

> \_ **Neither approve nor disapprove**

\_ **Somewhat disapprove**

\_ **Strongly disapprove**

**Form Approved**

**OMB No. 0930-0208**

**Expiration Date1/31/2007**

**CSAP GPRA Participant Outcome**

**Measures for Discretionary Programs**

**YOUTH - Age 12 to 17 Years**

Public reporting burden for this collection of information is estimated
to average 20 minutes per response if all items are asked of a
participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or
followup, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information to
SAMHSA Reports Clearance Officer, Room 16-105, 5600 Fishers Lane,
Rockville, MD 20857. 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 control number for
this project is 0930-0208.

**9/03**

**RECORD MANAGEMENT**

**Participant ID
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Contract/Grant ID
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Grant Year \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

> **Year**

**Interview Date \|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

**Interview Type**

> **1. Pre-Test 2. Post-Test 3. 6-Month Follow-up**

**A. DEMOGRAPHICS (QUESTIONS 1-4 ASKED ONLY AT BASELINE)**

**1. Gender**

> \_ **Male**
>
> \_ **Female**

**2. Are you Hispanic or Latino?**

> \_ **Yes** \_ **No**

**3. What is your race? (Select one or more)**

> \_ **Black or African American** \_ **Alaska Native**
>
> \_ **Asian** \_ **White**
>
> \_ **American Indian**
>
> \_ **Native Hawaiian or Other**  **Pacific Islander**

**4. What is your date of birth? \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|**

> **Month / Day / Year**

**B. DRUG AND ALCOHOL USE**

**1. How frequently have you smoked cigarettes during the past 30
days?**

> 1 Not at all
>
> 2 Less than one cigarette per day
>
> 3 One to five cigarettes per day
>
> 4 About one-half pack per day
>
> 5 About one pack per day
>
> 6 About one and one-half packs per day
>
> 7 Two packs or more per day

**2. How often have you taken smokeless tobacco during the past 30
days?**

> 1 Not at all
>
> 2 Once or twice
>
> 3 Once to twice per week
>
> 4 Three to five times per week
>
> 5 About once a day
>
> 6 More than once a day

**3. To be more precise, during the past 30 days about how many
cigarettes have you smoked per day?**

> 1 None
>
> 2 Less than 1 per day
>
> 3 1 to 2
>
> 4 3 to 7
>
> 5 8 to 12
>
> 6 13 to 17
>
> 7 18 to 22
>
> 8 23 to 27
>
> 9 28 to 32
>
> 10 33 to 37
>
> 11 38 or more

**Alcoholic beverages include beer, wine, wine coolers, and liquor.**

4.  On how many occasions during the last 30 days have you had alcoholic
    beverages to drink (more than just a few sips)?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

5.  On how many occasions during the last 30 days (if any) have you been
    drunk or very high from drinking alcoholic beverages?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

6.  On how many occasions during the last 30 days (if any) have you used
    marijuana (grass, pot) or hashish (hash, hash oil)?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

7.  During the LAST MONTH, about how many marijuana cigarettes (joints,
    reefers), or the equivalent, did you smoke a day, on the average?
    (If you shared them with other people, count only the amount YOU
    smoked).

> 1 None
>
> 2 Less than 1 a day
>
> 3 1 a day
>
> 4 2 to 3 a day
>
> 5 4 to 6 a day
>
> 6 7 to 10 a day
>
> 7 11 or more a day

8.  On how many occasions during the last 30 days (if any) have you
    sniffed glue, or breathed the contents of aerosol spray cans, or
    inhaled any other gases or sprays in order to get high?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

9.  **On how many occasions (if any) during the last 30 days have you
    taken LSD ('acid')?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

**Amphetamines are sometimes called: uppers, ups, speed, bennies,
dexies, pep pills, diet pills, meth or crystal meth. They include the
following drugs: Benzedrine, Dexedrine, Methedrine, Ritalin, Preludin,
Dexamyl, and Methamphetamine.**

10. On how many occasions (if any) during the last 30 days have you
    taken amphetamines on your own that is, without a doctor telling you
    to take them?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

11. On how many occasions (if any) during the last 30 days have you
    taken 'crack' (cocaine in chunk or rock form)?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

12. On how many occasions (if any) during the last 30 days have you
    taken cocaine in any other form (like cocaine powder)?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

13. Tranquilizers are sometimes prescribed by doctors to calm people
    down, quiet their nerves, or relax their muscles. Librium, Valium,
    and Miltown are all tranquilizers. On how many occasions (if any)
    have you taken tranquilizers on your own that is, without a doctor
    telling you to take them\...during the last 30 days?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

14. Barbiturates are sometimes prescribed by doctors to help people
    relax or get to sleep. They are sometimes called downs, downers,
    goofballs, yellows, reds, blues, rainbows. On how many occasions (if
    any) have you taken barbiturates on your own that is, without a
    doctor telling you to take them\...during the last 30 days?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

**15. On how many occasions (if any) have you smoked (or inhaled the
fumes of) crystal meth ('ice')\...during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

16. Amphetamines have been prescribed by doctors to help people lose
    weight or to give people more energy. They are sometimes called
    uppers, ups, speed, bennies, dexies, pep pills, and diet pills.
    Drugstores are not supposed to sell them without a prescription from
    a doctor. Amphetamines do NOT include any non-prescription drugs,
    such as over-the-counter diet pills (like Dexatrim) or stay-awake
    pills (like No-Doz), or any mail-order drugs. On how many occasions
    (if any) have you taken amphetamines on your own that is, without a
    doctor telling you to take them\...during the last 30 days?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

17. On how many occasions (if any) have you used heroin\...during the
    last 30 days?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

18. **There are a number of narcotics other than heroin, such as
    methadone, opium, morphine, codeine, demerol, paregoric, talwin, and
    laudanum. They are sometimes prescribed by doctors. On how many
    occasions (if any) have you taken narcotics other than heroin on
    your own that is, without a doctor telling you to take
    them\...during the last 30 days?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

19. On how many occasions (if any) have you used MDMA ('ecstasy') during
    the last 30 days?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

20. On how many occasions (if any) have you used Rohypnol ('rophies,'
    'roofies') during the last 30 days?

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

21. During the last 30 days, on how many occasions (if any) have you
    used GHB ('liquid G,' 'grievous bodily harm')**?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

22. During the last 30 days, on how many occasions (if any) have you
    used **Ketamine ('special K,' 'super K')?**

> 1 0 occasions
>
> 2 1 to 2 occasions
>
> 3 3 to 5 occasions
>
> 4 6 to 9 occasions
>
> 5 10 to 19 occasions
>
> 6 20 to 39 occasions
>
> 7 40 or more occasions

**23. On how many occasions (if any) in your lifetime have you had an
alcoholic beverage‑more than just a few sips?**

\_ **Never**

\_ **1 to 2**

\_ **3 to 5**

\_ **6 to 9**

\_ **10 to 19**

\_ **20 to 39**

\_ **40 or more**

**24. How old were you the [first time]{.underline} you smoked part or
all of a cigarette?**

> years old If you never smoked part or all of a cigarette please mark
> the box. 

**25. Think about the [first time]{.underline} you had a drink of an
alcoholic beverage. How old were you the first time you had a drink of
an alcoholic beverage? Please do not include any time when you only had
a sip or two from a drink.**

years old If never had a drink of an alcoholic beverage please mark the
box. 

**26. How old were you the [first time]{.underline} you used marijuana
or hashish?**

> years old If never used marijuana or hashish please mark the box. 

**27. How old were you the [first time]{.underline} you used any other
illegal drugs?**

> **years old If never used any illegal drugs please mark the box. **

**D. EDUCATION, EMPLOYMENT, AND INCOME**

**1. What is the highest level of education you have finished, whether
or not you received a degree? \[01=1st grade, 12=12th grade, 13=college
freshman, 16=college completion\]**

> \|\_\_\_\_\|\_\_\_\_\| level in years

**G. ATTITUDES AND BELIEFS**

10668. It is clear to my friends that I am committed to living a
       drug-free life.

> \_ False
>
> \_ Maybe
>
> \_ True

1.  I have made a final decision to stay away from marijuana.

> \_ False
>
> \_ Maybe
>
> \_ True

2.  I have decided that I will smoke cigarettes.

> \_ False
>
> \_ Maybe
>
> \_ True

3.  I plan to get drunk sometime in the next year.

> \_ False
>
> \_ Maybe
>
> \_ True

**5. How much do you think people risk harming themselves (physically or
in other ways) if they smoke one or more packs of cigarettes per day?**

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

\_ **Can't say/Drug unfamiliar**

**6. How much do you think people risk harming themselves (physically or
in other ways) if they try marijuana once or twice?**

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

\_ **Can't say/Drug unfamiliar**

**7. How much do you think people risk harming themselves (physically or
in other ways) if they smoke marijuana regularly?**

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

\_ **Can't say/Drug unfamiliar**

8.  How much do you think people risk harming themselves (physically or
    in other ways) if they take one or two drinks nearly every day?

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

\_ **Can't say/Drug unfamiliar**

9.  How much do you think people risk harming themselves (physically or
    in other ways) if they have five or more drinks once or twice each
    weekend?

> \_ **No risk**
>
> \_ **Slight risk**
>
> \_ **Moderate risk**
>
> \_ **Great risk**

\_ **Can't say/Drug unfamiliar**

**10. How wrong do you think it is for someone your age to drink beer,
wine or hard liquor (for example, vodka, whiskey or gin) regularly?**

> \_ Very wrong
>
> \_ Wrong
>
> \_ **A little bit wrong**
>
> \_ **Not wrong at all**

11. How wrong do you think it is for someone your age to smoke
    cigarettes?

> \_ Very wrong
>
> \_ Wrong
>
> \_ A little bit wrong
>
> \_ Not wrong at all

12. How wrong do you think it is for someone your age to smoke
    marijuana?

> \_ Very wrong
>
> \_ Wrong
>
> \_ A little bit wrong
>
> \_ **Not wrong at all**

13. How wrong do you think it is for someone your age to use LSD,
    cocaine, amphetamines or another illegal drug?

> \_ Very wrong
>
> \_ Wrong
>
> \_ A little bit wrong
>
> \_ **Not wrong at all**