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* 1. I am

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* 2. I am in______________ grade.

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* 3. How old are you?

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* 4. I consider myself mostly to be

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* 5. In the past 30 days

  Never 0 times 1 time 2 times 3 times 4 or more times
have you had alcoholic beverages (beer, wine, cocktails, hard liquor, etc.) to drink--more than just a few sips?
have you smoked cigarettes?
have you used Marijuana?
have you used prescription drugs not prescribed to you?
have you used synthetic drugs (k2, bath salts, night lights, etc.?

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* 6. During the past 30 days, on how many days did you use prescription drugs that were not prescribed for you or that you took only for the experience or feeling they caused?

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* 7. The friends I spend time with

  No Not Sure Sometimes Regularly
drink alcohol
smoke cigarettes
use marijuana
chew tobacco
use prescription drugs not prescribed for them
use synthetic drugs (k2. bath salts, night lights, etc.)

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* 8. The friends I spend time with encourage me to

  No Not Sure Sometimes Regularly
drink alcohol
use tobacco
use marijuana
use prescription drugs not prescribed for me
use over the counter drugs not for a health reason
use synthetic drugs (k2, bath salts, night lights, etc.)

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* 9. How wrong do your parents feel it would be for you

  Not at all wrong A little bit wrong Wrong Very Wrong
to have one or two drinks of an alcoholic beverage nearly every day
to smoke cigarettes
to use smokeless tobacco
to smoke marijuana
to use prescription drugs not prescribed for me
to use over the counter drugs not for a health reason
to use synthetic drugs (k2, bath salts, night lights, etc.)

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* 10. Because of my drinking alcohol or using drugs

  I do not drink or use drugs No Not Sure Sometimes Regularly
there have been problems at home or school
I did something I wish I hadn't done
there have been arguments
something happened that I wish hadn't happened
there have been physical fights
I cannot remember what happens

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* 11. In the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?

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* 12. During the past 30 days, on how many days did you have 5 or more drinks on the same occasion?

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* 13. If you wanted to drink alcohol tonight or this weekend, how easy would it be for you to get alcohol such as beer, wine, or liquor?

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* 14. Where do you drink alcohol?

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* 15. When do you drink alcohol?

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* 16. Within the past 30 days, have you driven a car, motorcycle, ATV/UTV, truck or other vehicle after or when you've been drinking alcohol?

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* 17. How wrong do our friends feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day?

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* 18. How wrong do your friends feel it would be for you to smoke tobacco?

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* 19. How wrong do your friends feel it would be for you to smoke marijuana?

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* 20. How wrong do your friends feel it would be for you to use prescription drugs not prescribed for you?

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* 21. How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?

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* 22. How wrong do your friends feel it would be to

  Not at all wrong A little bit wrong Wrong Very wrong
have one or two drinks of an alcoholic beverage nearly every day?
smoke tobacco?
use smokeless tobacco?
smoke marijuana?
use prescription drugs not prescribed to you?
use over the counter drugs not for the intended purpose?
use synthetic drugs (k2, bath salts, night lights) ?

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* 23. Do you have friends who have been caught or penalized for

  Yes No
Alcohol use?
Marijuana use?
Synthetic drug use?
Prescription drug use?
Tobacco use?

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* 24. How much do you think people risk harming themselves (physically or in other ways) if they

  No Risk Slight Risk Moderate Risk Great Risk
take five or more drinks of an alcoholic beverage (beer, wine, liquor) once or twice a week?
take one or two drinks of an alcoholic beverage (beer, wine, liquor) nearly every day?
smoke one or more packs of cigarettes per day?
marijuana once or twice a week?
use prescription drugs that are not prescribed to them?
use synthetic drugs?
Use prescription drugs that are not prescribed to them or that they took only for the experience or feeling it caused?

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* 25. Where do youth obtain

  Home with parent knowledge Home without parent knowledge Older friends Older siblings Merchants Not Applicable
Alcohol
Marijuana
Tobacco

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* 26. How well do you do in school?

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* 27. I worry about my grades.

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* 28. Do you participate in school activities such as Sports, Music, Drama or other School clubs or activities?

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* 29. I am comfortable talking to my family when something is troubling me.

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* 30. In the past 7 days, roughly how many hours have you spent playing video games (e.g. XBox, PS4, other gaming consoles, mobile phones, computer, etc.)

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* 31. What video games do you play most?

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* 32. With whom do you play video games?  (Select the best answer)

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* 33. In the past 7 days, roughly how many hours have you spent using social media on your phone, computer or other device? (Facebook, Snapchat etc.)

0 100 hours
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 34. Please provide any comments you may have.

T