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

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* 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)

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* 2. Please enter today's date.

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* 3. Please enter your city and state.

Please select whether the following statements are true or false.

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

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

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

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

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* 8. Drug addiction is a genetic disorder.

Please select one answer for the following question.

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

Please answer the following question in your own words.

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

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* 11. Please enter your email address.

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* 12. Please enter your phone number.

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Image

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

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

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* 15. What is your age?

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* 16. What is your gender?

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* 17. How many children do you have?

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

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

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* 20. How did you hear about our class?

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