Choice Pass Survey 2015

Please complete this short survey and answer all questions honestly.  Your responses will remain anonymous.
Note to parents: In order to obtain honest responses, it is critical that you student complete this survey on their own.

Question Title

* 1. Which school do you currently attend?

Question Title

* 2. What grade are you in?

Question Title

* 3. What is your gender?

Question Title

* 4. Which race/ethnicity best describes you? (Please choose only one.)

Question Title

* 5. How do each of the following apply to your reasons for wanting a Choice Pass?

  Importance rating
To motivate me to make healthy choices
To engage more with friends
For a discounted ski pass
For other discounts
Because my friends are making the Choice
Because my community celebrates my healthy choices

Question Title

* 6. Do you participate in any extracurricular activities at school such as sports, band, drama, clubs, or student government?

Question Title

* 7. Read each of the following statements and indicate your level of agreement based on how they describe you as an individual at this time.

  Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
I understand my strengths.
I feel confident with myself.
It is important for me to be successful in school, a job, or my future career.
If I had a personal problem, I could ask my parents or guardians for help.
It is easy for me to talk with my parents or guardians about alcohol and drugs.
My parents talk with me often about the dangers of drugs and alcohol.
There are a lot of chances for students at my school to get involved in sports, clubs, and other school activities outside of class.
There are a lot of chances for students at my school to attend alcohol and drug-free events outside of class.

Question Title

* 8. During the past 30 days, on how many days did you:

  Mark one
smoke cigarettes?
have at least one drink of alcohol?
have 5 or more drinks of alcohol in a row, that is, within a couple of hours?
use marijuana?
take a prescription drug without a doctor's prescription?

Question Title

* 9. During the past 30 days, on how many days do you think a typical student at your school:

  Mark one
smoked cigarettes?
drank alcohol?
had 5 or more drinks of alcohol in a row, that is, within a couple of hours?
used marijuana?
taken a prescription drug without a doctor's prescription?

Question Title

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

  Mark one
smoke one or more packs of cigarettes per day?
have one or two drinks of alcohol nearly every day?
use marijuana regularly?

Question Title

* 11. During the past 12 months, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use?

Question Title

* 12. During the past 7 days, on how many days did you eat breakfast?

T