WestCare Arizona
Drug-Free Communities (DFC)
CORE Measures Survey

This survey is important as we hope to gain valuable information about your experiences and perceptions of tobacco, alcohol, marijuana, and prescription drug (i.e., opioid) use.

Thank you for your participation!

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* 1. Sex:

Male

Female

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* 2. Grade:

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* 3. Age:

10 years old or less

11 years old

12 years old

13 years old

14 years old

15 years old

16 years old

17 years old

18 years old

19 years old or more

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* 4. 30-Day Use

	Yes	No
During the past 30 days did you drink one or more drinks of an alcoholic beverage?	During the past 30 days did you drink one or more drinks of an alcoholic beverage? Yes	During the past 30 days did you drink one or more drinks of an alcoholic beverage? No
During the past 30 days did you smoke part or all of a cigarette?	During the past 30 days did you smoke part or all of a cigarette? Yes	During the past 30 days did you smoke part or all of a cigarette? No
During the past 30 days have you used marijuana or hashish?	During the past 30 days have you used marijuana or hashish? Yes	During the past 30 days have you used marijuana or hashish? No
During the past 30 days did you take prescription medications (i.e., opioids) that were not prescribed to you?	During the past 30 days did you take prescription medications (i.e., opioids) that were not prescribed to you? Yes	During the past 30 days did you take prescription medications (i.e., opioids) that were not prescribed to you? No

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* 5. Perception of Risk

	No Risk	Slight Risk	Moderate Risk	Great Risk
How much do you think people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?	How much do you think people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week? No Risk	How much do you think people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week? Slight Risk	How much do you think people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week? Moderate Risk	How much do you think people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week? Great Risk
How much do you think people risk harming themselves physcially or in other ways if they smoke one or more packs of cigarettes per day?	How much do you think people risk harming themselves physcially or in other ways if they smoke one or more packs of cigarettes per day? No Risk	How much do you think people risk harming themselves physcially or in other ways if they smoke one or more packs of cigarettes per day? Slight Risk	How much do you think people risk harming themselves physcially or in other ways if they smoke one or more packs of cigarettes per day? Moderate Risk	How much do you think people risk harming themselves physcially or in other ways if they smoke one or more packs of cigarettes per day? Great Risk
How much do you think people risk harming themselves physically or in other ways if they smoke marijuana once or twice a week?	How much do you think people risk harming themselves physically or in other ways if they smoke marijuana once or twice a week? No Risk	How much do you think people risk harming themselves physically or in other ways if they smoke marijuana once or twice a week? Slight Risk	How much do you think people risk harming themselves physically or in other ways if they smoke marijuana once or twice a week? Moderate Risk	How much do you think people risk harming themselves physically or in other ways if they smoke marijuana once or twice a week? Great Risk
How much do you think people risk harming themselves physically or in other ways if they take prescription medications (i.e., opioids) that were not prescribed to them once or twice a week?	How much do you think people risk harming themselves physically or in other ways if they take prescription medications (i.e., opioids) that were not prescribed to them once or twice a week? No Risk	How much do you think people risk harming themselves physically or in other ways if they take prescription medications (i.e., opioids) that were not prescribed to them once or twice a week? Slight Risk	How much do you think people risk harming themselves physically or in other ways if they take prescription medications (i.e., opioids) that were not prescribed to them once or twice a week? Moderate Risk	How much do you think people risk harming themselves physically or in other ways if they take prescription medications (i.e., opioids) that were not prescribed to them once or twice a week? Great Risk

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* 6. Perception of Parental Disapproval

	Not at all wrong	A little bit wrong	Wrong	Very wrong
How wrong do your parents feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day?	How wrong do your parents feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day? Not at all wrong	How wrong do your parents feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day? A little bit wrong	How wrong do your parents feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day? Wrong	How wrong do your parents feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day? Very wrong
How wrong do your parents feel it would be for you to smoke tobacco?	How wrong do your parents feel it would be for you to smoke tobacco? Not at all wrong	How wrong do your parents feel it would be for you to smoke tobacco? A little bit wrong	How wrong do your parents feel it would be for you to smoke tobacco? Wrong	How wrong do your parents feel it would be for you to smoke tobacco? Very wrong
How wrong do your parents feel it would be for you to smoke marijuana?	How wrong do your parents feel it would be for you to smoke marijuana? Not at all wrong	How wrong do your parents feel it would be for you to smoke marijuana? A little bit wrong	How wrong do your parents feel it would be for you to smoke marijuana? Wrong	How wrong do your parents feel it would be for you to smoke marijuana? Very wrong
How wrong do your parents feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you?	How wrong do your parents feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you? Not at all wrong	How wrong do your parents feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you? A little bit wrong	How wrong do your parents feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you? Wrong	How wrong do your parents feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you? Very wrong

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* 7. Perception of Peer Disapproval

	Not at all wrong	A little bit wrong	Wrong	Very wrong
How wrong do your friends feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day?	How wrong do your friends feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day? Not at all wrong	How wrong do your friends feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day? A little bit wrong	How wrong do your friends feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day? Wrong	How wrong do your friends feel it would be for you to have one or two drinks of an alcoholic beverage nearly every day? Very wrong
How wrong do your friends feel it would be for you to smoke tobacco?	How wrong do your friends feel it would be for you to smoke tobacco? Not at all wrong	How wrong do your friends feel it would be for you to smoke tobacco? A little bit wrong	How wrong do your friends feel it would be for you to smoke tobacco? Wrong	How wrong do your friends feel it would be for you to smoke tobacco? Very wrong
How wrong do your friends feel it would be for you to smoke marijuana?	How wrong do your friends feel it would be for you to smoke marijuana? Not at all wrong	How wrong do your friends feel it would be for you to smoke marijuana? A little bit wrong	How wrong do your friends feel it would be for you to smoke marijuana? Wrong	How wrong do your friends feel it would be for you to smoke marijuana? Very wrong
How wrong do your friends feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you?	How wrong do your friends feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you? Not at all wrong	How wrong do your friends feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you? A little bit wrong	How wrong do your friends feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you? Wrong	How wrong do your friends feel it would be for you to take prescription medications (i.e., opioids) that were not prescribed to you? Very wrong

WestCare Arizona Drug-Free Communities (DFC) CORE Measures Survey

Question Title

* 1. Sex:

Question Title

* 2. Grade:

Question Title

* 3. Age:

Question Title

* 4. 30-Day Use

Question Title

* 5. Perception of Risk

Question Title

* 6. Perception of Parental Disapproval

Question Title

* 7. Perception of Peer Disapproval

WestCare Arizona
Drug-Free Communities (DFC)
CORE Measures Survey