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2014
October
S
Substance Use Survey
Substance Use Survey
Substance Use Survey: Beliefs and Life Experiences
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Hello:
You are invited to participate in my academic research survey on Substance Use: Beliefs and Life Experiences. In this survey, approximately 8-14 people will be asked to complete a survey that asks questions about demographics, beliefs, history of substance use and how your life experiences have impacted you as an individual. It will take approximately 30 minutes to complete the questionnaire.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Jen Kirkpatrick at (919)-597-1030 or by email at
[email protected]
Thank you very much for your time and support. Please start with the survey now by clicking on the
Continue
button below.
What is your gender?
Male
Female
What is your marital status?
Single (Never married)
Married
Domestic partnership
Widowed
Divorced
Separated
Don’t know
What is your age?
Younger than 18
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 or older
Prefer not to answer
What is the highest level of education you have achieved?
Less than high school degree
High school degree or equivalent (e.g. GED)
Some college but no degree
Associate degree (e.g. AA, AS)
Bachelor's degree (e.g. BA, AB, BS)
Master's degree (e.g. MA, MS, MBA)
Professional degree (e.g. MD, DDS, JD)
Doctorate degree (e.g. PhD)
Please describe your current residence:
Owned by you or someone in household with a mortgage or loan
Owned by you or someone in household free and clear (no mortgage or loan)
Rented
Occupied without payment of rent
How many children do you have?
no children
1 child
2 children
3 children
more than 4 children
Which category best describes your annual income?
Under $15,000
$15,000 - $29,999
$30,000 - $44,999
$45,000 - $59,999
$60,000 - $74,999
$75,000 - $89,999
$90,000 - $104,999
$105,000 - $119,999
$120,000 or more
Prefer not to answer
Please select your Hobbies and Interest
Auto racing
Biking
Boating
Bowling
Camping
Crafts
Dancing
Fine Arts
Fishing
Gambling
Gardening
Hiking
Hunting
Horseback riding
Kayaking
Martial Arts
Music
Photography
Reading
Sports
Travel
Other
I can usually keep myself from using substances by paying close attention to my emotions.
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
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