Project EX

Pre-Clinic Student Survey

SCHOOL NAME:______

BIRTH DATE:_ _ - _ _ - _ _ _ _

MONTH DAY YEAR

AGE:_ _

GENDER:_ _

M F

GRADE:_____

THINGS TO REMEMBER:

  • Read each question carefully.
  • Circle only one letter for each question, unless the question asks for more than one answer.
  • Raise your hand when you have questions or if there are any words you don’t understand.
  • When you finish this survey, turn it over and sit quietly until the rest of the group finishes.
  • All of your answers are confidential.

Part I. The first set of questions asks about your background.

1.What is your ethnic background?

[Please circle the one category that bestapplies.If you circle “b” (Asian) or “c”

(Latino), please alsocheck the specific categorythat applies to you.]

a.Black/African American

b.Asian/Pacific Islander (Chinese , Japanese , Filipino, Korean ,

other , specify )

c.Latino/Hispanic (Mexican-American , Central American , South American , other , specify )

d.White/Non-Latino

e.Native American

f.Other ethnic group: ______

  1. Who do you live with? (Circle one.)
  1. Both parents (or stepparents)
  2. Only with my mother (or stepmother)
  3. Only with my father (or stepfather)
  4. Sometimes with my mother (or stepmother) and sometimes with my father (or stepfather)
  5. Other person(s)
  6. Alone

3.What made you decide to come today?

______

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Part II. THE NEXT FEW QUESTIONS ASK ABOUT YOUR DRUG USE BEHAVIOR. PLEASE ANSWER EACH QUESTION HONESTLY. REMEMBER YOUR ANSWERS ARE CONFIDENTIAL.

4.How many cigarettes do you smoke in an average day? _____

5.How many cigarettes did you smoke yesterday? _____

6.How many times have you used cigarettes in the last month

(30 days)?______

7.Did you smoke tobacco today?

____ Yes

No

8.Did you inhale any smoke-able product today?

____ Yes

No

9.How many times have you used smokeless tobacco (chewing tobaccoor snuff) in the last month (30 days)?

(0 to 100+ times)

10.How many times have you smoked a (tobacco) cigar in the last month(30 days)?

(0 to 100+ times)

11.How many times have you smoked a clove cigarette in the last month(30 days)?

(0 to 100+ times)

12.How many times have you tried cigarettes in your whole life?

(0 to 100+ times)

13.How many times have you used alcohol in the last month (30 days)?

(0 to 100+ times)

14.How many times have you used marijuana in the last month (30days)?

(0 to 100+ times)

15.How many times have you used a hard drug, such as cocaine,stimulants, inhalants, hallucinogens, depressants, P.C.P., or opiates, in the last month (30 days)?

(0 to 100+ times)

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16.Which of the following describes your thoughts about quittingcigarette smoking? (Please circle only ONE response.)

a. I’ve never smoked cigarettes.

b. I’ve never thought about quitting.

c. I’ve thought about quitting and decided I don’t want to.

d. I’ve thought about quitting, but haven’t made up my mind.

e. I plan to quit, but not until later.

f. I plan to quit right away.

g.I am taking action to quit right now.

h. I’ve quit and I’m trying to stay off.

17.How likely is it that you will smoke cigarettes in the next 12 months?

Would you say...

a.Definitely not

b.Probably not

c.A little likely

d.Somewhat likely

e.Very likely

18.Do you think you will ever quit smoking cigarettes?

  1. Yes, I already have
  2. Yes, I will sometime in the future
  3. Yes, I will in the next few weeks
  4. Maybe
  5. No
  6. I never smoke cigarettes

19.How many times have you tried to quit smoking in your life?

a.I don’t smoke

b.More than five times

c.Three or four times

d.One or two times

e.Never

20.How many cigarettes a day do you smoke?

a.Over 26 cigarettes a day

b.About 16-25 cigarettes a day

c.About 1-15 cigarettes a day

d.Less than 1 a day

21.Do you inhale?

a.Always

b.Quite often

c.Seldom

d.Never

e.I never smoke cigarettes

22.How soon after you wake up do you smoke your first cigarette?

a.Within the first 30 minutes

b.More than 30 minutes after waking but before noon

c.In the afternoon

d.In the evening

e.I never smoke cigarettes

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23.Which cigarette would you hate to give up?

a.First cigarette in the morning

b.Any other cigarette before noon

  1. Any other cigarette in the afternoon

d.Any other cigarette in the evening

e.I never smoke cigarettes

24.Do you find it difficult to refrain from smoking in places where it is forbidden (church, library, movies, etc.)?

a. Yes, very difficult

b.Yes, somewhat difficult

c.No, not usually difficult

d.No, not at all difficult

25.Do you smoke if you are so ill that you are in bed most of the day?

a.Yes, always

b.Yes, quite often

c.No, not usually

d.No, never

26.Do you smoke more during the first 2 hours of the day than during the rest of the day?

a.Yes

b.No

27.If you have attempted to quit smoking, how hard was it to quit?

a.Not at all hard

b.Somewhat hard

c.Very hard

d.Extremely hard

e.I’ve never tried to quit smoking

28.Of the five people who are closest to you (family and friends), how many are smokers?

  1. Five
  2. Four
  3. Three
  4. Two
  5. One
  6. None

29.How much energy do you have to quit tobacco now and/or stay stopped?

a.A lot

b.Some

c.A little

d.None

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30.How much effort will you put in to quit tobacco now and/or stay stopped?

a.A lot

b.Some

c.A little

d.None

31.How much direction do you feel you are receiving to quit now and/or staystopped?

a.A lot

b.Some

c.A little

d.None

32.How much do you desire to quit tobacco now and/or stay stopped?

a.A lot

b.Some

c.A little

d.None

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