Wading Through the Data Swamp:
Program Evaluation 201

Supplements

YOUTH SURVEY
(12 years old and over)

RECORD MANAGEMENT

Client ID |____|____|____|____|____|____|____|____|____|____|____|
Contract/Grant ID |____|____|____|____|____|____|____|____|____|____|
Grant Year |________|
Interview Date |____|____| / |____|____| / |____|____|

Interview Type

__PRETEST
__POSTTEST
__6-MONTH FOLLOWUP
__12-MONTH FOLLOWUP

DEMOGRAPHICS (QUESTIONS 1-4 ASKED ONLY AT BASELINE)

  1. Gender

  2. __ Male
    __ Female
    __ Other (please specify) ________________

  3. Are you Hispanic or Latino?
  4. __ Yes __ No

  5. What is your race?
  6. __ Black or African American __ Alaska Native
    __ Asian __ White
    __ American Indian __ Other
    __ Native Hawaiian or other Pacific Islander   (Specify)_____________

  7. What is your date of birth?
  8. |____|____| /
    Month    		 |____|____| /
    Day    		 |____|____|
    Year

DRUG AND ALCOHOL USE

  1. During the past 30 days how many days have you used the following:
  2.  

    Number of Days
    a. Any alcohol

    |____|____|
    b. Alcohol to intoxication (5+ drinks in one setting)

    |____|____|
    c. Other illegal drugs

    |____|____|

  3. During the past 30 days how many day have you used any of the following:
  4.  

    Number of Days
    a. Cocaine/crack

    |____|____|
    b. Marijuana/hashish, pot

    |____|____|

    c. Heroin or other opiates

    |____|____|

    d. Nonprescription methadone

    |____|____|

    e. PCP or other hallucinogens/ psychedelics, LSD, mushrooms, mescaline

    |____|____|

    f. Methamphetamine or other amphetamines, uppers

    |____|____|

    g. Benzodiazepines, barbiturates, other tranquilizers, downers, sedatives, or hypnotics

    |____|____|

    h. Inhalants, poppers, rush, whippets

    |____|____|

    i. Other Drugs-Specify________________

    |____|____|

  5. Now think about the past 30 days-that is, from DATEFILL up to and including today. During the past 30 days, have you smoked part or all of a cigarette?
  6. __ Yes __ No

  7. During the past 30 days, that is since DATEFILL, on how many days did you use chewing tobacco? _________ # of Days

  8. Now think about the past 30 days-that is, from DATEFILL up to and including today. During the past 30 days, have you used snuff, even once?
  9. __ Yes __ No

  10. Now think about the past 30 days-that is, from DATEFILL up to and including today. During the past 30 days, have you smoked part or all of any type of cigar?
  11. __ Yes __ No

  12. During the past 30 days, that is, since DATEFILL, have you smoked tobacco in a pipe, even once?
  13. __ Yes __ No

  14. On how many occasions (if any) have you had alcohol to drink-more than just a few sips?

  15. __ Never
    __ 1-2
    __ 3-5
    __ 6-9
    __ 10-19
    __ 20-39
    __ 40 or more

  16. How old were you the first time you smoked part or all of a cigarette?

  17. ___ years old

    If never smoked part or all of a cigarette please mark the box 

  18. Think about the first time you had a drink of an alcoholic beverage. How old were you the first time you had a drink of an alcoholic beverage? Please do not include any time when you only had a sip or two from a drink.

  19. AGE: ___

    If never had a drink of an alcoholic beverage please mark the box 

  20. How old were you the first time you used marijuana or hashish?

  21. AGE: ___

    If never used marijuana or hashish please mark the box 

  22. How old were you the first time you used any other illegal drugs?

  23. AGE: ___

    If never used any illegal drugs please mark the box 

FAMILY AND LIVING CONDITIONS

  1. During the past 30 days how stressful have things been for you because of your use of alcohol or other drugs?

  2. __ Not at all
    __ Somewhat
    __ Considerably
    __ Extremely

  3. During the past 30 days has your use of alcohol or other drugs caused you to reduce or give up important activities?

  4. __ Not at all
    __ Somewhat
    __ Considerably
    __ Extremely

  5. During the past 30 days has your use of alcohol and other drugs caused you to have emotional problems?

  6. __ Not at all
    __ Somewhat
    __ Considerably
    __ Extremely

ATTITUDES AND BELIEFS

  1. It is clear to my friends that I am committed to living a drug-free life.

  2. __ False
    __ Maybe
    __ True

  3. I have made a final decision to stay away from marijuana.

  4. __ False
    __ Maybe
    __ True

  5. I have decided that I will smoke cigarettes.

  6. __ False
    __ Maybe
    __ True

  7. I plan to get drunk sometime in the next year.

  8. __ False
    __ Maybe
    __ True

  9. How much do people risk harming themselves physically and in other ways when they smoke one or more packs of cigarettes per day?

  10. __ No risk
    __ Slight risk
    __ Moderate risk
    __ Great risk
    __ Can't Say/Drug Unfamiliar

  11. How much do people risk harming themselves physically and in other ways when they smoke marijuana once a month or more?

  12. __ No risk
    __ Slight risk
    __ Moderate risk
    __ Great risk
    __ Can't Say/Drug Unfamiliar

  13. How much do people risk harming themselves physically and in other ways when they smoke marijuana once or twice a week?

  14. __ No risk
    __ Slight risk
    __ Moderate risk
    __ Great risk
    __ Can't Say/Drug Unfamiliar

  15. How much do you think people risk harming themselves physically and in other ways when they have four or more drinks of an alcoholic beverage nearly everyday?

  16. __ No risk
    __ Slight risk
    __ Moderate risk
    __ Great risk
    __ Can't Say/Drug Unfamiliar

  17. How much do you think people risk harming themselves physically and in other ways when they have four or more drinks of an alcoholic beverage once or twice a week?

  18. __ No risk
    __ Slight risk
    __ Moderate risk
    __ Great risk
    __ Can't Say/Drug Unfamiliar

  19. How wrong do you think it is for someone your age to drink beer, wine or hard liquor (for example, vodka, whiskey, or gin) regularly?

  20. __ Very wrong
    __ Wrong
    __ A little bit wrong
    __ Not wrong at all

  21. How wrong do you think it is for someone your age to smoke cigarettes?

  22. __ Very wrong
    __ Wrong
    __ A little bit wrong
    __ Not wrong at all

  23. How wrong do you think it is for someone your age to smoke marijuana?

  24. __ Very wrong
    __ Wrong
    __ A little bit wrong
    __ Not wrong at all

  25. How wrong do you think it is for someone your age to use LSD, cocaine, amphetamines, or another illegal drug?

  26. __ Very wrong
    __ Wrong
    __ A little bit wrong
    __ Not wrong at all

EDUCATION, EMPLOYMENT, AND INCOME

  1. What is the highest level of education you have finished, whether or not you received a degree? [01=1st grade, 12=12th grade, 13=college freshman, 16=college completion]

  2. |____|____| level in years

    1a. If less than 12 years of education, do you have a GED (General Equivalency Diploma)?

    __ Yes __ No

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