You are being asked to take part in a study of family, peers, and community behaviors surrounding alcohol and other substance use. The purpose of the study is to inform and improve state and local substance use prevention programs. Ultimately, the results of this survey may be published by state and local substance use prevention programs; however, the published results will describe aggregated (added together) data so no one individual participant can be identified. 
 
1. If you are currently under the age of 18 or over the age of 25 or if you have already completed this survey online or at another location this summer, please do not complete this survey and (if in paper form) return this form to the administrator.

2. Taking this survey is completely voluntary. You may skip any questions that you do not want to answer. You may withdraw from the survey at any time without consequences.

3. Please do not put your name on this survey. All information you provide will be kept anonymous.

4. The approximate length of time to complete this survey is 10 to 15 minutes.

The survey contains several questions about your alcohol and substance use and consequences of use. There are no known direct benefits to you, although you may be benefiting your community. There is the risk that you may experience discomfort in answering some of the questions. There are resources for you if you would like to talk to someone about substance use; please contact the New York State HOPEline at 1-877-8-HOPENY (1-877-846-7369) or use the information provided to you by the administrators of this survey.

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* 1. Are you:

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* 2. What is your age?

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* 3. Are you Hispanic or Latino?

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* 4. Please choose the responses that best describe you (select all that apply):

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* 5. What is your employment status?

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* 6. Are you a student?

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* 7. What is the zip code of the town or city where you live?

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* 8. Not including the town where you live, what is the zip code of the town or city where you spend the greatest amount of time (for example, where you work or attend school)?

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* 9. What is the main reason for spending time in this other town or city?

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* 10. During the past 12 months, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug abuse? (Choose all that apply.)

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* 11. How easy do you think it is for persons your age in your community to obtain...  (Check one bubble in each row.)

  Very easy Somewhat easy Somewhat difficult Very difficult
Prescription pain relievers (such as OxyContin, Percocet, Vicodin, or Tylox) that were not prescribed to them?
Prescription stimulants (such as Ritalin, Adderall, or Concerta) that were not prescribed to them?
Prescription tranquilizers or "benzos" (like Klonopin, Xanax, Valium, or Ativan) that were not prescribed to them?
Marijuana?
Heroin?
Any other drug?

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* 12. How much do people risk harming themselves physically and in other ways when they... (Check one bubble in each row.)

  No risk Slight risk Moderate risk Great risk
Smoke one or more packs of cigarettes per day?
Use an electronic vaping device or e-cigarette (Juuling, vaping, Bo vaping, vape pens, e-hookahs, hookah pens, vaping mods)?
Have five or more drinks of an alcoholic beverage once or twice a week?
Use prescription pain relievers (such as OxyContin, Percocet, Vicodin, or Tylox) that are not prescribed to them or that they took only for the experience or feeling they caused?
Use prescription stimulants (such as Ritalin, Adderall, or Concerta) that are not prescribed to them or that they took only for the experience or feeling they caused?
Use prescription tranquilizers (like Klonopin, Xanax, Valium, or Ativan) that are not prescribed to them or that they took only for the experience or feeling they caused?
Use marijuana regularly?
Use heroin?

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* 13. How do you think your parents would feel about you... (Check one bubble in each row.)

  Neither approve or disapprove Somewhat disapprove Strongly disapprove
Smoking cigarettes?
Using an electronic vaping device or e-cigarette (Juuling, vaping, Bo vaping, vape pens, e-hookahs, hookah pens, vaping mods)?
Having one or two drinks of an alcoholic beverage nearly every day?
Smoking marijuana?
Using prescription pain relievers (such as OxyContin, Percocet, Vicodin, or Tylox) that are not prescribed to you or that you took only for the experience or feeling they caused?
Using prescription stimulants (such as Ritalin, Adderall, or Concerta) that are not prescribed to you or that you took only for the experience or feeling they caused?
Using prescription tranquilizers (like Klonopin, Xanax, Valium, or Ativan) that are not prescribed to you or that you took only for the experience or feeling they caused?
Using heroin?

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* 14. How do you feel about someone your age... (Check one bubble in each row.)

  Neither approve or disapprove Somewhat disapprove Strongly disapprove
Smoking cigarettes?
Using an electronic vaping device or e-cigarette (Juuling, vaping, Bo vaping, vape pens, e-hookahs, hookah pens, vaping mods)?
Having one or two drinks or an alcoholic beverage nearly every day?
Having five or more drinks of an alcoholic beverage once or twice a week?
Driving after having one or two drinks?
Smoking marijuana?
Using prescription pain relievers (such as OxyContin, Percocet, Vicodin, or Tylox) that are not prescribed to them or that they took only for the experience or feeling they caused?
Using prescription stimulants (such as Ritalin, Adderall, or Concerta) that are not prescribed to them or that they took only for the experience or feeling they caused?
Using prescription tranquilizers (like Klonopin, Xanax, Valium, or Ativan) that are not prescribed to them or that they took only for the experience or feeling they caused?
Using heroin?

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* 15. During the past 30 days, on how many days did you... (Check one bubble in each row.)

  0 1-2 3-5 6-9 10-19 20-30
Smoke part or all of a cigarette?
Use an electronic vaping device or e-cigarette (Juuling, vaping, Bo vaping, vape pens, e-hookahs, hookah pens, vaping mods)?
Use marijuana?
Drink one or more drinks of an alcoholic beverage?
Have 5 or more drinks on the same occasion?
Use prescription pain relievers (such as OxyContin, Percocet, Vicodin, or Tylox) that were not prescribed to you or that you took only for the experience or feeling they caused?
Use prescription stimulants (such as Ritalin, Adderall, or Concerta) that were not prescribed to you or that you took only for the experience or feeling they caused?
Use prescription tranquilizers or "benzos" (like Klonopin, Xanax, Valium, or Ativan) that were not prescribed to you or that you took only for the experience or feeling they caused?
Use heroin?

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* 16. If you are under the age of 21 or turned 21 within the past year, and you drank alcohol in the past year, how did you usually get it? (Select all that apply.)

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* 17. The last time you used prescription Pain Relievers (such as OxyContin, Percocet, Vicodin, or Tylox) not prescribed to you, how did you get them? (Check only one.)

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* 18. The last time you used prescription Stimulants (such as Ritalin, Adderall, or Concerta) not prescribed to you, how did you get them? (Check only one.)

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* 19. The last time you used prescription Tranquilizers (like Klonopin, Xanax, Valium, or Ativan) not prescribed to you, how did you get them? (Check only one.)

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* 20. During the last 12 months, have you experienced any of following due to your use of alcohol, marijuana, prescription pain relievers, other prescription drugs, or heroin? (Check boxes if 'Yes')

  Alcohol Marijuana Prescription pain relievers Other prescription drugs Heroin
Performed poorly at school or work
Missed class or work
Got into an argument or fight
Driven a vehicle while under the influence
Been arrested for DWI/DUI
Rode in a vehicle while the driver was under the influence
Been in trouble with police or college authorities
Damaged property
Been hurt or injured
Forgot where I was or what I did
Done something I later regretted
Have been taken advantage of sexually
Have taken advantage of another sexually
Got nauseated or vomited
Had a hangover
Seriously thought about suicide
Seriously tried to commit suicide
Thought I might have a alcohol/drug problem
Tried unsuccessfully to stop using

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