SuperKids! Grade 5

Please respond to this survey by selecting ONE answer to each question. Thank you for participating.

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1. I am a:

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2. I am:

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3. The way you feel about yourself is:

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4. Peer pressure is being influenced by your:

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5. Which of the following actions would  NOT be a positive way to solve a conflict?

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6. For young people alcohol is most harmful because it can:

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7. Tobacco is most harmful because it can:

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8. Bullying is not which one of the following?

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9. If someone offers you a drink of alcohol, which should you  not do?

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10. When you get angry, what is the best question to ask yourself?

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11. Which is the best thing to do when walking outside?

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12. During the past 30 days, on how many days did you have at least one beer, wine cooler, glass of wine, or other alcohol?

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13. During the past 30 days, on how many days did you smoke cigarettes?

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14. During the past 30 days, on how many days did you use marijuana?

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15. During the past 30 days, on how many days did you smell something (or huff) on purpose to get high?  (Example: glue, gasoline, paint, etc.)

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16. Which of the following things do you think you might do in the next month?

  Yes Maybe No
Smoke a cigarette
Drink alcohol
Use drugs like marijuana or cocaine
Use "calm down" steps when you are mad
Get in a fight
Smell something to get high
Take someone else’s medicine

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