Please check or write in the answer that is most true for you. No names are required to fill out this survey. We hope you feel free to be completely honest since your answers are not attached to you personally. Your answers to the following questions will help us get a better understanding of some of the things facing young adults in Franklin County and a better understanding of young adult substance use.
TELL US ABOUT YOU!

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1. Optional to fill out information for Question #1

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2. How old are you?

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3. Are you:

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4. Are you a parent?

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5. Are you registered to vote?

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6. Highest grade of school completed:

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7. How many people live in your household?

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8. How many children age 17 or younger live in your household?

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9. What is your race?

TELL US ABOUT YOU AND WORK

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10. If you are employed full or part-time, how many hours do you work per week?

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11. In the last 3 months, have you been disqualified for employment or lost a job because you failed a drug test?

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12. When looking for a job, have you used any of the following sources?

  Yes No
Public Library
COWIC
Online lists of jobs
Job Readiness Program
Applied for a job online

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13. Are you looking for a job right now?

TELL US ABOUT YOU AND HOUSING

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14. Do you think your neighborhood is safe?

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15. Are you friends with some of your neighbors?

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16. Is your housing in decent shape?

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17. What kinds of things are in your neighborhood?

  Yes No
Carryout Store
Full Grocery Store
Park or Green Area
Gas Station
Library
Church
Streetlights
School
Daycare
TELL US ABOUT YOU AND THINGS YOU LIKE TO DO

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18. These are some kinds of things you might do. How often do you do each of the following?

  Never A few times a year Once or twice a month At least once a week Almost every day
Play a musical instrument or sing
Do creative writing – poems, raps, journals, open mike
Actively participate in sports, athletics, or exercising
Do art or craft work
Work around the house, yard, garden, car, etc.
Go to a shopping mall
Spend at least an hour of leisure time alone
Read books, magazines, or newspapers

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19. Think specifically about the past 30 days. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?

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20. Think about the first time you had a drink of an alcoholic beverage. How old were you the first time you had a drink of an alcoholic beverage? (Please do not include any time when you had only a sip or two from a drink.)

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21. Would you be more likely or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis?

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

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23. How do you like to drink?

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24. Did a parent or care-giver have a problem with alcohol?

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25. How much do people risk harming them-selves physically and in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?

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26. What was the size of the TYPICAL can, bottle, or glass of beer you drank during the last 12 months?

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27. What was the TYPICAL type of beer that you drank during the last 12 months?

TELL US ABOUT YOU AND THINGS YOU DO FOR FUN

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28. These are some kinds of things you might do. How often do you do each of the following?

  Never A few times a year Once or twice a month At least once a week Almost every day
Watch TV
Go to movies
Go to concerts
Go to church or a church-related event
Get together with friends informally
Go to taverns, bars, or nightclubs
Go to parties or other social affairs
Ride around in a car (or motorcycle) just for fun
TELL US ABOUT YOU AND ELECTRONICS

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29. Tell us about you and electronics

  Yes No
Do have access to the internet?
Do you have an e-mail account?
Do you use Twitter?
Do you post on YouTube?
Do you have a Facebook page?
Have you ever taken a course on line?

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30. What electronic devices do you have access to?

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31. How often do you visit a Social Networking website like Facebook or MySpace?

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32. How often do you play electronic games?

TELL US ABOUT YOU AND HOW YOU DEAL WITH PROBLEMS

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33. If you needed to turn to someone for advice or guidance, who would you most likely select? (Please select your one best answer).

TELL US ABOUT YOU AND HEALTH

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34. When was the last time you saw a doctor or nurse for a check-up (when you were not sick or injured)?

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35. When was the last time you saw a dentist for a check-up, exam, teeth cleaning or other dental work?

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36. On an average night, how many hours of sleep do you get?

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37. Where do you get most of your health care?

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38. How do you describe your weight?

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39. How many cigarettes do you smoke a day?

TELL US ABOUT YOU AND MUSIC

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40. What is your favorite kind of music?

TELL US ABOUT YOU AND MARIJUANA

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41. Think specifically about the past 30 days. During the past 30 days, on how many days did you use marijuana or hashish?

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42. How do you feel about someone your age trying marijuana or hashish once or twice?

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43. How do you feel about someone your age using marijuana or hashish once a month or more?

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44. How old were you the first time you used marijuana or hashish?

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45. How much do people risk harming them-selves physically and in other ways when they smoke marijuana one or twice a week?

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46. During the past 12 months, do you recall hearing, reading, or watching an advertisement about the prevention of sub-stance use?

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47. In the past 30 days how many days have you used marijuana at the same time you were drinking alcohol?

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