Skip to content
Student Survey
This survey asks questions about your knowledge, attitudes, and experience with vape/e-cigarettes. Please answer the best you can. Your responses are confidential. No one will know how you answered unless you tell them.
*
What school do you go to?
(Required.)
Ashby Lee Elementary School
WW Robinson Elementary School
Sandy Hook Elementary School
North Fork Middle School
Peter Muhlenberg Middle School
Signal Knob Middle School
Stonewall Jackson High School
Central High School
Strasburg High School
*
What grade are you in?
(Required.)
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Do any of the following people in your household use
vape/e-cigarettes
? (Check all that apply)
Mother/Female guardian
Father/male guardian
Grandparents
Other (for example, brother or sister)
No one in my house uses vape/e-cigarettes
Do any of the following people in your household
smoke cigarettes
? (Check all that apply)
Mother/Female guardian
Father/male guardian
Grandparents
Other (for example, brother or sister)
No one in my house smokes cigarettes
How many of your close friends use
vape/e-cigarettes
?
None of them
Some of them
Most of them
All of them
How many of your close friends
smoke cigarettes
?
None of them
Some of them
Most of them
All of them
Have you
ever used
an electronic cigarette/vape,
even once
? This includes JUUL,Puff Bar, vape pens, mods, or any other type of vape/e-cigarette.
No
Yes
Have you ever been curious about using a vape/e-cigarette?
Definitely yes
Probably yes
Probably not
Definitely not
Do you think that you will try a vape/e-cigarette soon?
Definitely yes
Probably yes
Probably not
Definitely not
If one of your best friends were to offer you a vape/e-cigarette, would you use it?
Definitely yes
Probably yes
Probably not
Definitely not
During the
past 30 days
, on how many days did you use a vape/e-cigarette?
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
How often do you currently use an e-cigarette or vaping device?
Daily or almost daily
Less than daily but at least weekly
Less than weekly but at least once a month
Once in a while
I do not currently use an e-cigarette or vaping device
Have you
ever
smoked or used ANY of the following tobacco products? This does
not
include vape/electronic cigarettes. (Check all that you have ever used).
Cigarettes
Cigars, including cigarillos and little filtered cigars
Smokeless tobacco, including chew, snuff, and snus
Hookah or waterpipe
Any other tobacco product
None of them
During the
past 30 days
, have you smoked or used ANY of the following tobacco products? This does
not
include vape/electronic cigarettes. (Check all that you have ever used).
I have not used tobacco in the past 30 days
Cigarettes
Cigars, including cigarillos and little filtered cigars
Smokeless tobacco, including chew, snuff, and snus
Hookah or waterpipe
Any other tobacco product