The following survey asks personal but important questions about your attitudes and behaviors regarding prescription drug use. Your responses will be helpful to the Augusta University team in helping plan health promotion activities at your school. Completing this survey is voluntary, and all responses will be kept anonymous. While we prefer for you to answer all of the questions, you may skip any you do not feel comfortable answering.
 
 
 

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* 1. What is your grade in school?

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* 2. How old are you?

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* 3. What is your racial or ethnic identification?

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* 4. What is your gender?

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* 5. Please rate how believable each of the following sources of information about prescription drugs are to you:

  Very Unbelievable Somewhat Unbelievable Don’t Know  Somewhat Believable Very Believable
Your parents
Your teachers
Your friends
The internet
A poster at school
A flyer/handout
School newspaper
The police, DARE, school resource officer
Religious organization or religious leader
Your coach
Student peer educator
School counselor
Nurse, doctor or other health professional

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* 6. About how often during this school year have you seen or heard information about what students at your school think about using prescription drugs not prescribed to them?

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* 7. Please fill in the circle for the number of days that you used each of the following types of prescription drugs not prescribed to you in the past 30 days.

 
0 days

1 to 9 days

10 to 19 days

20 to 30 days

Prescription pain killers (such as Hydrocodone/Hydros, Oxycodone/Oxy, Gabapentin/Gabbies, or Tramadol/Trammmies)

Prescription stimulants (such as Ritalin or Adderall)

Prescription sedatives or tranquilizers (such as Benzos, Xanax/Xans, Klonopin, or Ativan)

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* 8. Please select your level of agreement with the following statements:

 
Strongly Agree

Agree

Neutral
Disagree Strongly Disagree
Students should be told about the harmful side effects of taking prescrption drugs that were not prescribed for them.  
Prescription drugs should be stored in a secure location.
Taking prescription pain killers may lead to addiction.
Prescription drugs prescribed to me should not be shared with others. 
I would prefer to be friends with someone who does not take prescription drugs that belong to someone else.

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* 9. Please select your level of agreement with the following statements about students at your school.

 
Strongly Agree

Agree

Neutral
Disagree Strongly Disagree
The typical student at my school believes that students should be told about the harmful side effects of taking prescrption drugs that were not prescribed for them.
The typical student at my school believes that prescription drugs should be stored in a secure location.
The typical student at my school believes that taking prescription pain killers may lead to addiction.
The typical student at my school believes they should not share their medications with others.
The typical student at my school would prefer to be friends with someone who does not take prescription drugs that belong to someone else.
For the next set of questions, please use the slider to select a number between 0 and 100 to indicate the percentage of students at Tutt Middle School you think used the following prescription medications without a prescription in the past 30 days.

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* 10. What percentage of students at Tutt Middle School do you think have used prescription pain killers not prescribed to them in the past 30 days? (Examples of prescription pain killers include Hydrocodone/Hydros, Oxycodone/Oxy, Gabapentin/Gabbies, and Tramadol/Trammies.)

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 11. What percentage of students at Tutt Middle School do you think have used prescription stimulants not prescribed to them in the past 30 days? (Examples of prescription stimulants include Adderall, Ritalin and Concerta.)

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 12. What percentage of students at Tutt Middle School do you think have used prescription tranquilizers or sedatives not prescribed to them in the past 30 days? (Examples of tranquilizers and sedatives include Benzos, Xanax/Xans, Klonopin, and Ativan.)

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 13. When hanging out or socializing with friends, what do you typically do? (check all that apply)

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* 14. When hanging out or socializing with friends, what does the typical student at your school do? (check all that apply)

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* 15. When you have been at a party or just hanging out with other students or peers, what have you done to avoid using prescription or other drugs? (select all that apply)

Thank you for your participation! PLEASE HIT THE "DONE" BUTTON BELOW TO
SUBMIT YOUR SURVEY

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