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0%
 
 
* What is your age?
 
11
 
12
 
13
 
14
 
15
 
16
 
17
 
18
 
 
 
* What is your gender?
 
Male
 
Female
 
 
At what age did you first use
Did Not Use Under 10 10-11 12-13 14-16 17-19
* Tobacco (smoke, chew, snuff)
* Alcohol (beer, wine, liquor)
* Marijauna
* Other illegal drugs
 
 
Within the last 30 days how often have you used
Did Not Use One time per month One time per week Multiple times weekly Daily
* Tobacco (smoke, chew, snuff)
* Alcohol (beer, wine, liquor)
* Marijuana
* Other illegal drugs
 
 
If you have not used any of the following, why have you chosen not to: Please Check ALL that Apply to you:
Risks Not Legal Beliefs Parents Not Available No Desire
Tobacco (smoke, chew, snuff)
Alcohol (beer, wine, liquor)
Marijuana
Other illegal drugs
 
 
How do you think your close friends feel (or would feel) about you
Don’t Disapprove Disapprove Strongly Disapprove
* Smoking tobacco occasionally
* Smoking tobacco regularly
* Drinking alcohol occasionally
* Drinking alcohol regularly
* Smoking marijuana occasionally
* Smoking marijuana regularly
* Using illegal drugs occasionally
* Using illegal drugs regularly
 
 
Do you believe that alcohol has the following effects?
Yes No
* Allows people to have more fun
* Enhances social activity
* Makes it easier handle stress
* Helps connect with peers
* Helps male bonding
* Facilitates sexual opportunities
* Helps female bonding
* Harms your driving skills
 
 
 
* Would you ever drink and drive?
 
Never
 
Maybe
 
Depends on the situation
 
Yes
 
 
 
* If you wanted to get your hands on tobacco, alcohol, or drugs, how easy would it be?
 
Very Difficult
 
Somewhat Difficult
 
No problem
 
Extremely Easy
 
 
 
Do you feel The Power House provides a safe drug and alcohol free environment?
 
Yes
 
No
 
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