EPI/AAK 032 (1/6) 92 Ver. 1. Project Northland Questionnaire

Transcription

1 EPI/AAK 032 (1/6) 92 Ver. 1 Project Northland Questionnaire

2 Part 1 We would like you to give honest answers to these questions about alcohol and drugs. No one will see your answers with your names. Please try to give an answer to each question. Use a pencil to FILL IN the circles. 1. ARE YOU...? 1 White 4 Hispanic 2 Black 5 Asian 3 Native American 6 Other 2. DO YOU LIVE WITH...? 1 Both parents 4 Father mostly 2 Parent and step-parent 5 Other relative 3 Mother mostly 6 Foster parents 7 Other 3. PLEASE TELL US WHAT YOU KNOW ABOUT ALCOHOL BY ANSWERING TRUE, FALSE, OR DON'T KNOW. DON'T TRUE FALSE KNOW Drinking alcohol gives people energy Young people who drink alcohol are more likely to get into fights and arguments Crack and cocaine cause more deaths in young people than does alcohol Not many people my age drink alcohol Most people my age will drink alcohol by the time they are seniors in high school People my age who drink alcohol are likely to get into trouble with the police Beer, alcohol, and wine advertisements try to get people my age to think it's cool to drink PLEASE TELL US ABOUT ALCOHOL AND YOUR PARENTS BY ANSWERING TRUE, FALSE, OR DON'T KNOW. DON'T TRUE FALSE KNOW My parents do NOT want people my age to drink My parents talk with me about problems drinking alcohol can cause young people My family has rules against young people drinking alcohol I think my parents will allow me to drink by the time I am a high school senior I would get into trouble (be punished) if my parents found out that I was drinking alcohol EPI/AAK 020 (2/13) 3/92 Ver. 1 1

3 5. PLEASE TELL US HOW MUCH OF THE TIME YOUR PARENTS ASK WHERE YOU ARE GOING OR WHO YOU WILL BE WITH. 1 Never 2 Rarely 3 Some of the time 4 Most of the time 5 All of the time 6. PLEASE TELL US HOW HARD OR DIFFICULT IT IS FOR PEOPLE YOUR AGE TO GET ALCOHOL IF THEY TRIED TO... NOT AT ALL VERY DIFFICULT DIFFICULT...buy beer, wine, or hard liquor at a store themselves? ask an older brother or sister to buy it for them? ask another older person to buy it for them? order a drink in a bar? sneak it from their home or a friend's home? find a party that has alcohol they could drink? HOW SURE ARE YOU THAT YOU COULD SAY "NO" IF YOU WERE OFFERED ALCOHOL IN THESE SITUATIONS? COULD NOT COULD NOT SAY NO SURE SAY NO At a friend's house? By an older brother or sister? By other older persons? At a party or dance? By a boyfriend or girlfriend? HOW SURE ARE YOU THAT YOU COULD AVOID GETTING INTO A CAR DRIVEN BY SOMEONE WHO HAS BEEN DRINKING? I could avoid riding I'm not sure I could NOT avoid riding with a drinking driver if I could with a drinking driver DURING THE LAST 30 DAYS, HOW MANY TIMES HAVE YOU RIDDEN IN A CAR WHEN... 2 TO 4 5 OR MORE NONE ONCE TIMES TIMES...the driver had been drinking? you think the driver had 5 or more drinks? DOES YOUR BEST FRIEND... YES NO DON'T KNOW...drink alcohol? smoke cigarettes? EPI/AAK 020 (3/13) 3/92 Ver. 1 2

4 11. PLEASE TELL US HOW MANY OF YOUR FRIENDS... ALMOST ALL NONE OF THEM...smoke cigarettes regularly? use chewing or smokeless tobacco? drink alcohol? have gotten drunk so they fell down or got sick? use marijuana? sniff glue, gas, sprays or anything like that to get high? use cocaine or crack? use any other drugs to get high? HOW OFTEN HAVE YOUR FRIENDS ASKED YOU TO... MANY NEVER TIMES...smoke cigarettes? drink alcohol? get drunk? use marijuana? sniff glue, gas, sprays or anything like that to get high? use cocaine or crack? use any other drugs to get high? NOW WE'D LIKE TO ASK YOU ABOUT YOUR USE OF TOBACCO. PLEASE BE VERY HONEST AND REMEMBER THAT NO ONE WILL SEE YOUR ANSWERS. Have you ever smoked cigarettes? Have you ever used chewing or smokeless tobacco? 1 Never 1 Never 2 Once or twice 2 Once or twice 3 Occasionally but not regularly 3 Occasionally but not regularly 4 Regularly in the past 4 Regularly in the past 5 Regularly now 5 Regularly now NOTE FOR THE FOLLOWING QUESTIONS Alcoholic beverages = Glass of wine Bottle of beer Shot glass of liquor SIPS DON'T COUNT! Mixed drink 14. NOW WE'D LIKE TO ASK YOU ABOUT YOUR USE OF ALCOHOLIC BEVERAGES, INCLUDING BEER, WINE, AND LIQUOR... (Mark one circle for each line) On how many occasions have you had alcoholic beverages to drink......in your lifetime? during the last 12 months? during the last 30 days? during the last 7 days? occasions 1-2 occasions 3-5 occasions 6-9 occasions occasions occasions 40 or more occasions EPI/AAK 020 (4/13) 3/92 Ver. 1 3

5 15. THINK BACK OVER THE LAST TWO WEEKS. HOW MANY TIMES HAVE YOU HAD FIVE OR MORE DRINKS IN A ROW? 1 None 4 Three to five times 2 Once 5 Six to nine times 3 Twice 6 Ten or more times 16. HAVE YOU EVER GOTTEN REALLY DRUNK SO YOU FELL DOWN OR GOT SICK? Never 1-2 times 3 or more times HOW OFTEN DO YOU ATTEND ACTIVITIES OR PARTIES WHERE... MANY NEVER TIMES...your friends or others your age drink alcohol? no alcohol is present? HOW LIKELY IS IT THAT YOU'LL DRINK AN ALCOHOLIC BEVERAGE... LIKELY I WOULD NOT SURE WHAT LIKELY I NOT DRINK I WOULD DO WOULD DRINK...when you are an adult 21 years or older? if someone offered it to you in the next 12 months? in the next 30 days? in the next 7 days? EPI/AAK 020 (5/13) 3/92 Ver. 1 4

6 19. NOW WE'D LIKE TO ASK ABOUT YOUR USE OF ANY OTHER DRUGS. PLEASE BE VERY HONEST AND REMEMBER THAT NO ONE WILL SEE YOUR ANSWERS. 0 occasions 1-2 occasions 3-5 occasions 6-9 occasions occasions occasions In your lifetime, have you or more occasions During the last 12 months, have you... During the last 30 days, have you... During the last 7 days, have you PLEASE TELL US WHETHER YOU EVER DID ANY OF THE FOLLOWING IN SCHOOL BY FILLING IN THE CIRCLE. YOU CAN CHOOSE MORE THAN ONE, BUT ONLY FILL IN THOSE YOU REMEMBER CLEARLY. a) 1 Discussed what can happen to people who drink alcohol. b) 1 Saw films about car crashes. c) 1 Discussed why young people start to drink. d) 1 Learned about how advertisements encourage drinking. e) 1 Did skits to practice refusing alcohol. f) 1 Made a pledge to not drink until I'm older. g) 1 Had homework with parents about alcohol. h) 1 Listened to someone from the police talk about alcohol. i) 1 Elected peer leaders to lead classes about alcohol. EPI/AAK 020 (6/13) 3/92 Ver. 1 5

7 21. PLEASE TELL US IF YOU REMEMBER PARTICIPATING IN ANY OF THE FOLLOWING HEALTH EDUCATION PROGRAMS IN YOUR SCHOOL OR HOME BY FILLING IN THE CIRCLE NEXT TO THE PROGRAM. ONLY CHOOSE THOSE PROGRAMS YOU REMEMBER CLEARLY. YOU CAN CHOOSE MORE THAN ONE. a) 1 The Slick Tracy Home Team g) 1 Growing Healthy b) 1 Quit and Win h) 1 Here's Looking At You 2000 c) 1 Shifting Gears i) 1 The Minnesota Smoking Prevention Program d) 1 Amazing Alternatives! j) 1 Values and Choices e) 1 Project DARE k) 1 Tobacco and Alcohol Connection f) 1 Project Quest l) 1 Smoke Free Generation 22. CHOOSE ANY OF THE FOLLOWING THINGS THAT MIGHT HAPPEN IF A STUDENT IN YOUR SCHOOL IS CAUGHT DRINKING ALCOHOL. YOU CAN CHOOSE MORE THAN ONE. a) 1 Student is given a warning. b) 1 Parents are told. c) 1 Student has to stay after school. d) 1 Student can be suspended. e) 1 I don't know what might happen. 23. A YOUNG PERSON CAN HAVE MANY REASONS NOT TO USE ALCOHOL. PLEASE RATE HOW IMPORTANT EACH OF THESE REASONS IS TO YOU. NOT TOO IMPORTANT FOR ME VERY IMPORTANT FOR ME There are many other ways to have fun besides drinking alcohol My parents have rules against alcohol use by people my age I'm afraid I might become an alcoholic There are many bad things that could happen to me if I drink alcohol Drinking alcohol costs too much money Alcohol use can be bad for my health Using alcohol could hurt my performance as a student or athlete I want to be able to make my own decisions and not give in to peer pressure CONTINUE WITH PART 2 EPI/AAK 020 (7/13) 3/92 Ver. 1 6