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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.

Once the survey is complete click DONE on the last page to finish registering for Choice Pass.

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* 1. Which school do you currently attend?

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* 2. What is your gender?

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* 3. What grade are you in?

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

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* 5. What language do you speak at home?

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* 6. How do each of the following help you choose to do 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
Because my parents want me to be in Choice Pass

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

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* 8. Read each of the following statements and indicate your level of agreement based on how you describe yourself 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.

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* 9. In the past 30 days did you (check all that apply):

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

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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 (such as
OxyContin, Percocet, Vicodin, codeine,
Adderall, Ritalin, or Xanax) without a doctor's prescription?
vaped?

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* 11. 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?
use vapes regularly?

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

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* 13. During the past 12 months, have you talked with at least one of your parents about healthy relationships and consent?

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* 14. During the past 30 days, how many times did you ride
in a car or other vehicle driven by someone who had
been drinking alcohol?

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