Please provide us with the following information about yourself. Your answers will be kept private.

* 1. Please enter your name. (This is the name that will appear on the Certificates of Completeness when you complete section 2 and the last online survey)

* 2. Please enter today's date.

* 3. Please enter your city and state.

Please select whether the following statements are true or false.

* 4. It is safe to take prescription medications prescribed to a family member, but only if you have the same symptoms.

* 5. Taking prescription medications to get high is safer than using illicit drugs such as cocaine or heroin.

* 6. Most teens who abuse drugs do so to rebel against their parents.

* 7. Taking prescription drugs prescribed to someone else is illegal.

* 8. Drug addiction is a genetic disorder.

Please select one answer for the following question.

* 9. Where do most teens get the prescription medications they use to get high?

Please answer the following question in your own words.

* 10. Please describe two ways you can help prevent your child from abusing prescription medications.

* 11. Please enter your email address.

* 12. Please enter your phone number.


* 13. Do you recall seeing the image/message above?

* 14. If so, where do you remember seeing the image/message above. List all.

* 15. What is your age?

* 16. What is your gender?

* 17. How many children do you have?

* 18. What is the age of your child/children?

* 19. How many of your children are girls and how many are boys?

* 20. How did you hear about our class?