Project EX
Post-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 also check 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: ______
- Who do you live with? (Circle one.)
- Both parents (or stepparents)
- Only with my mother (or stepmother)
- Only with my father (or stepfather)
- Sometimes with my mother (or stepmother) and sometimes with my father (or stepfather)
- Other person(s)
- Alone
Part II. The next set of questions asks about the Project EX class (group). PLEASE RATE EACH OF THE FOLLOWING ON A SCALE OF ONE (NOT AT ALL) TO TEN (EXTREMELY).
3.How helpful was the class for quitting smoking?
(Not at all) 1 23 4 5 6 7 8 9 10(Extremely)
4.How interesting was the class?
(Not at all) 1 2 3 4 5 6 7 8 9 10(Extremely)
5.How much did you like the class?
(Not at all) 1 2 3 4 5 6 7 8 9 10(Extremely)
6.How informative was the class?
(Not at all) 1 2 3 4 5 6 7 8 9 10(Extremely)
7.How well organized was the class?
(Not at all) 1 2 3 4 5 6 7 8 9 10(Extremely)
8.How much did you learn in the class?
(Not at all) 1 2 3 4 5 6 7 8 9 10(Extremely)
9.How enthusiastic was the teacher (leader) of the class?
(Not at all) 1 2 3 4 5 6 7 8 9 10(Extremely)
10.How well informed was the teacher (leader) of the class?
(Not at all) 1 2 3 4 5 6 7 8 9 10(Extremely)
1
PLEASE RATE THE FOLLOWING ACTIVITIES ON A SCALE OF ONE (TERRIBLE) TO TEN (EXCELLENT). IF YOU WERE NOT IN CLASS THAT DAY OR DON’T REMEMBER THE ACTIVITY, PLEASE SKIP THE QUESTION.
11.Talk Show: Family and Friends Confront Smokers About Their Habit
(Terrible) 1 2 3 4 5 6 7 8 9 10 (Excellent)
12.Talk Show: Cigarettes May be Stressing You Out
(Terrible) 1 2 3 4 5 6 7 8 9 10 (Excellent)
13.Healthy Breathing
(Terrible) 1 2 3 4 5 6 7 8 9 10 (Excellent)
14.Game: Is Smoking on the Menu?
(Terrible) 1 2 3 4 5 6 7 8 9 10 (Excellent)
15.Talk show: Quitting Smoking: I’ve Been There and It Does Get Better
(Terrible) 1 2 3 4 5 6 7 8 9 10 (Excellent)
16.Yoga
(Terrible) 1 2 3 4 5 6 7 8 9 10 (Excellent)
17.Meditation
(Terrible) 1 2 3 4 5 6 7 8 9 10
(Excellent)
18.Talk Show: WARNING! Waiting to Quit Smoking may Be Hazardous to
Your Peace of Mind
(Terrible) 1 2 3 4 5 6 7 8 9 10 (Excellent)
19.Did taking the Project EX class help you to do any of the following?
(Please circle the ONEanswer that best applies.)
a.Quit tobacco use completely
b.Reduce the amount of tobacco you use, and you plan to quit completely
c.Reduce the amount of tobacco you use, but you do not plan toquit completely
d.Decide to quit smoking in the next two weeks
e.Decide to quit smoking sometime in the future
f.Strengthen your commitment to stay tobacco free (if you had alreadyquit smoking)
g.Other (please specify)______
20.Which of the following reasons did you have for attending the Project EX
group sessions? (Please circle ALL THAT APPLY.)
a.To get class credit
b.To get out of class
c.To get food
d.To learn about how tobacco affects me
e.To quit smoking
f.Other (please specify)______
21.What was your NUMBER ONE reason for attending the Project EXsessions? (Please circle only ONE.)
a.To get class credit
b.To get out of class
c.To get food
d.To learn about how tobacco affects me
e.To quit smoking
f.Other (please specify)
22.Please rate the following sessions on a scale of ONE (your mostfavorite)
to EIGHT (your least favorite). Do not include sessions youdid not attend
or do not remember.
Session One: Orientation
Session Two: Tobacco Can Affect Your Life
Session Three: Physiological Health Risks From Tobacco
Session Four: Breaking an Addiction: Step 1- Making a Commitment
Session Five: Breaking an Addiction: Step 2- Managing Withdrawal
Symptoms
Session Six: Maintenance: Taking Care of a Healthy Body
Session Seven: Maintenance: Taking Care of Your Peace of Mind
Session Eight: Avoiding Relapse
1
Part III. THE NEXT FEW QUESTIONS ASK ABOUT YOUR DRUG USE BEHAVIOR. PLEASE ANSWER EACH QUESTION HONESTLY. REMEMBER YOUR ANSWERS ARECONFIDENTIAL.
23.How many cigarettes do you smoke in an average day? _____
24.How many cigarettes did you smoke yesterday? _____
25.How many times have you used cigarettes in the last month
(30 days)?______
26.Did you smoke tobacco today?
____ Yes
No
27.Did you inhale any smoke-able product today?
____ Yes
No
28.How many times have you used smokeless tobacco (chewing tobaccoor snuff) in the last month (30 days)?
(0 to 100+ times)
29.How many times have you smoked a (tobacco) cigar in the last month(30 days)?
(0 to 100+ times)
30.How many times have you smoked a clove cigarette in the last month(30 days)?
(0 to 100+ times)
31.How many times have you tried cigarettes in your whole life?
(0 to 100+ times)
32.How many times have you used alcohol in the last month (30 days)?
(0 to 100+ times)
33.How many times have you used marijuana in the last month (30days)?
(0 to 100+ times)
34.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
35.Which of the following describes your thoughts about quitting cigarette
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.
36.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
37.Do you think you will ever quit smoking cigarettes?
- Yes, I already have
- Yes, I will sometime in the future
- Yes, I will in the next few weeks
- Maybe
- No
- I never smoke cigarettes
38.How many times have you tried to quit smoking in your life?
- I don’t smoke
- More than five times
c.Three or four times
- One or two times
e.Never
39.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
40.Do you inhale?
a.Always
- Quite often
c.Seldom
- Never
e.I never smoke cigarettes
41.How soon after you wake up do you smoke your first cigarette?
- Within the first 30 minutes
- More than 30 minutes after waking but before noon
c.In the afternoon
- In the evening
e.I never smoke cigarettes
1
42.Which cigarette would you hate to give up?
- First cigarette in the morning
b.Any other cigarette before noon
- Any other cigarette in the afternoon
d.Any other cigarette in the evening
e.I never smoke cigarettes
43.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
44.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
45.Do you smoke more during the first 2 hours of the day than during the rest of the day?
a.Yes
b.No
46.If you have attempted to quit smoking, how hard was it to quit?
- Not at all hard
b.Somewhat hard
- Very hard
d.Extremely hard
- I’ve never tried to quit smoking
47.Of the five people who are closest to you (family and friends), how many are
smokers?
- Five
- Four
- Three
- Two
- One
- None
48.How much energy do you have to quit tobacco now and/or stay stopped?
a.A lot
b.Some
c.A little
d.None
1
49.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
50.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
51.How much do you desire to quit tobacco now and/or stay stopped?
a.A lot
b.Some
c.A little
d.None
1