PREVENTION NEEDS ASSESSMENT SURVEY

PREVENTION NEEDS ASSESSMENT SURVEY 1. Thak you or agreeig to participate i this survey. The purpose o this survey is to lear how studets i our schools eel about their commuity, amily, peers, ad school. The survey also asks about health behaviors. 2. The survey is completely volutary ad aoymous. DO NOT put your ame o the questioaire. 3. This is ot a test, so there are o right or wrog aswers. We would like you to work quickly so you ca iish. 4. All o the questios should be aswered by completely illig i oe o the aswer spaces. I you do ot id a aswer that its exactly, use the oe that comes closest. I ay questio does ot apply to you, or you are ot sure what it meas, just leave it blak. You ca skip ay questio that you do ot wish to aswer. 5. For questios that have the ollowig aswers: NO! o yes YES! Mark (the BIG) NO! i you thik the statemet is DEFINITELY NOT TRUE or you. Mark (the little) o i you thik the statemet is MOSTLY NOT TRUE or you. Mark (the little) yes i you thik the statemet is MOSTLY TRUE or you. Mark (the BIG) YES! i you thik the statemet is DEFINITELY TRUE or you. Example: Chocolate is the best ice cream lavor. NO! o yes YES! I the example above, the studet marked "yes" because he or she thiks the statemet is mostly true. 6. Please mark oly oe aswer or each questio by completely illig i the circle with a #2 Please ill i the ollowig iormatio with the help o your teacher/survey assistat. School Number: 0 1 2 3 4 5 6 7 8 9 000 School District Number: 0 00 111 1 11 222 2 22 333 3 33 444 4 44 555 5 55 666 6 66 777 7 77 888 8 88 999 9 99 1. Are you: MALE FEMALE 4. Please choose the ONE aswer that BEST describes what you cosider yoursel to be? 2. How old are you? 10 or youger 12 14 16 18 11 13 15 17 19 or older 3. What grade are you i? 6th 7th 8th 9th 10th 11th 12th America Idia/Native America, Eskimo, or Aleut Asia Black, or Arica America Paciic Islader Spaish/Hispaic/Latio White, ot o Hispaic origi Multi-racial or other (Please Speciy ) Bach Harriso, L.L.C. 116 S. 500 E. Salt Lake City, Utah, 84102 Phoe: (801) 359-2064 ID

The ext sectio asks about your experieces at school. 18. Durig the LAST FOUR WEEKS how may whole days o school have you missed because you skipped or 'cut'? NO! o yes YES! Noe 1 2 3 4-5 6-10 11 or more 5. I my school, studets have lots o chaces to help decide thigs like class activities ad rules. The ext questios ask about your eeligs ad 6. My teacher(s) otices whe experieces i other parts o your lie. I am doig a good job ad lets me kow about it. 7. There are lots o chaces or studets i my school to get ivolved i sports, clubs, ad other school activities outside o class. 19. Thik o your our best rieds (the rieds you eel closest to). I the past year (12 moths), how may o your best rieds have: 8. There are lots o chaces 9. The school lets my parets or studets i my school to talk with a teacher oe-o-oe. Number o rieds 0 1 2 3 4 kow whe I have doe somethig well. a. smoked cigarettes? 10. My teachers praise me whe I work hard i school. b. tried beer, wie or hard liquor (or example, vodka, whiskey, or gi) whe their parets did't kow about it? 11. Are your school grades better tha the grades o most studets c. used marijuaa? i your class? d. used LSD, cocaie, amphetamies, 12. I have lots o chaces to be or other illegal drugs? part o class discussios or activities. e. bee suspeded rom school?. carried a hadgu? 13. Now thikig back over Almost always Ote g. sold illegal drugs? the past year i school, Sometimes how ote did you: h. stole or tried to steal a motor Seldom vehicle such as a car or motorcycle? Never i. bee arrested? a. ejoy beig i school? j. dropped out o school? b. hate beig i school? c. try to do your best work i school? 14. How ote do you eel that the school work you are assiged is meaigul ad importat? 20. What are the chaces you would be see as cool i you: Very good chace Pretty good chace Some chace Little chace No or very little chace 15. Puttig them all together, what were your grades like last year? a. smoked cigarettes? Mostly F's Mostly B's b. worked hard at school? Mostly D's Mostly A's Mostly C's c. bega drikig alcoholic beverages regularly, that is, at least oce or twice 16. How importat do you thik the thigs you are a moth? learig i school are goig to be or your later lie? d. deeded someoe who was beig Very importat Slightly importat verbally abused at school? Quite importat Not at all importat Fairly importat e. smoked marijuaa? 17. How iterestig are most o your courses to you?. regularly voluteered to do commuity service? Very iterestig ad stimulatig Quite iterestig Slightly dull Fairly iterestig Very dull 2

21. How old were you whe you irst: a. smoked marijuaa? 17 or older 16 15 14 13 12 11 10 or youger Never 23. Now thik about all the studets i your grade at your school. How may o them do you thik... Almost All (91-100%) Most (71-90%) Hal or more (51-70%) Hal or less (31-50%) Some (11-30%) Few (1-10%) Noe (0%) a. Smoke oe or more cigarettes a day? b. smoked a cigarette, eve just a pu? c. had more tha a sip or two o beer, wie or hard liquor (or example, vodka, whiskey, or gi)? d. bega drikig alcoholic beverages regularly, that is, at least oce or twice a moth? b. Drak alcohol sometime i the past moth? c. Used marijuaa sometime i the past moth? d. Used a illegal drug i the past moth (ot icludig marijuaa)? e. used pheoxydie (pox, px, breeze)?. got suspeded rom school? g. got arrested? h. carried a hadgu? i. attacked someoe with the idea o seriously hurtig them? 24. How may times i the past year (12 moths) have you: 40+ times 30 to 39 times 20 to 29 times 10 to 19 times 6 to 9 times 3 to 5 times 1 to 2 times Never a. bee suspeded rom school? b. carried a hadgu? c. sold illegal drugs? 22. How wrog do you thik it is or someoe your age to: Not Wrog at All A Little Bit Wrog Wrog Very Wrog d. stole or tried to steal a motor vehicle such as a car or motorcycle? e. bee arrested? a. take a hadgu to school? b. steal aythig worth more tha $5? c. pick a ight with someoe? d. attack someoe with the idea o seriously hurtig them? e. stay away rom school all day whe their parets thik they are at school?. drik beer, wie or hard liquor (or example, vodka, whiskey, or gi) regularly? g. smoke cigarettes?. attacked someoe with the idea o seriously hurtig them? g. bee druk or high at school? h. take a hadgu to school? i. participated i clubs, orgaizatios or activities at school? j. doe extra work o your ow or school? k. voluteered to do commuity service? h. smoke marijuaa? i. use LSD, cocaie, amphetamies or aother illegal drug? 25. Have you ever beloged to a gag? No Yes, i the past No, but would like to Yes, belog ow Yes, but would like to get out 3

26. You're lookig at CD's i a music store with a ried. You look up ad see her slip a CD uder her coat. She smiles ad says "Which oe do you wat? Go ahead, take it while obody's aroud." There is obody i sight, o employees ad o other customers. What would you do ow? 30. How ote do you atted religious services or activities? Never 1-2 Times a Moth Rarely About Oce a Week or More 31. I do the opposite o what people tell me, just to get Igore her them mad. Grab a CD ad leave the store Very False Somewhat True Tell her to put the CD back Somewhat False Very True Act like it is a joke, ad ask her to put the CD back 32. I like to see how much I ca get away with. Very False Somewhat True 27. You are visitig aother part o tow, ad you do't kow ay o the people your age there. You are walkig Somewhat False Very True dow the street, ad some teeager you do't kow is 33. I igore rules that get i my way. walkig toward you. He is about your size, ad as he is about to pass you, he deliberately bumps ito you ad Very False Somewhat True you almost lose your balace. What would you say or do? Somewhat False Very True Push the perso back Say "Excuse me" ad keep o walkig NO! o yes YES! Say "Watch where you are goig" ad keep o walkig 34. I thik sometimes it's okay to Swear at the perso ad walk away cheat at school. 35. Sometimes I thik that lie is ot worth it. 36. At times I thik I am o good at all. 28. You are at a party at someoe's house, ad oe o 37. All i all, I am iclied to thik that your rieds oers you a drik cotaiig alcohol. What I am a ailure. would you say or do? 38. I the past year, have you elt Drik it depressed or sad MOST days, eve i you elt okay sometimes? Tell your ried, "No thaks, I do't drik" ad suggest that you ad your ried go ad do somethig else 39. It is all right to beat up people i they start the ight. Just say, "No thaks" ad walk away 40. I thik it is okay to take somethig Make up a good excuse, tell your ried you had without askig i you ca get away with it. somethig else to do, ad leave 29. It's 8:00 o a weekight ad you are about to go over to a ried's home whe your mother asks you where you are goig. You say "Oh, just goig to go hag out with some rieds." She says, "No, you'll just get ito trouble i you go out. Stay home toight." What would you do ow? 41. How much do you thik people risk themselves (physically or i other ways) i they: Great Risk Moderate Risk Slight Risk No Risk a. smoke oe or more packs o Leave the house ayway cigarettes per day? Explai what you are goig to do with your rieds, tell her whe you will get home, ad ask i you ca go out b. try marijuaa oce or twice? c. smoke marijuaa regularly? Not say aythig ad start watchig TV d. take oe or two driks o a Get ito a argumet with her alcoholic beverage (beer, wie, liquor) early every day? 4

OCCASIONS O how may occasios (i ay) have you: 0 1-2 3-5 6-9 10-19 20-39 40+ 42. had alcoholic beverages (beer, wie, or hard liquor) to drik i your lietime-- more tha just a ew sips? 43. had alcoholic beverages to drik durig the past 30 days--more tha just a ew sips? 44. used marijuaa (grass, pot) or hashish (hash, hash oil) i your lietime? 45. used marijuaa (grass, pot) or hashish (hash, hash oil) durig the past 30 days? 46. used LSD (acid) or other hallucioges (like PCP, mescalie, peyote, "shrooms" or psilocybi) i your lietime? 47. used LSD (acid) or other hallucioges (like PCP, mescalie, peyote, "shrooms" or psilocybi) durig the past 30 days? 48. used cocaie (like cocaie powder) or "crack" (cocaie i chuk or rock orm) durig the past 30 days? 49. used cocaie (like cocaie powder) or "crack" (cocaie i chuk or rock orm) i your lietime? 50. sied glue, breathed the cotets o a aerosol spray ca, or ihaled other gases or sprays, i order to get high i your lietime? 51. sied glue, breathed the cotets o a aerosol spray ca, or ihaled other gases or sprays, i order to get high durig the past 30 days? 52. used pheoxydie (pox, px, breeze) i your lietime? 53. used pheoxydie (pox, px, breeze) durig the past 30 days? 54. used methamphetamie (meth, speed, crak, crystal meth) by ay method i your lietime? 55. used methamphetamie (meth, speed, crak, crystal meth) by ay method durig the past 30 days? Amphetamies have bee prescribed by doctors to help people loose weight or give people more eergy. They are sometimes called uppers, ups, speed, beies, dexies, pep pills, ad diet pills. Amphetamies do Not iclude over-the-couter diet pills (like Dexatrim ), or stay awake pills (like No-Doze ), or ay mail-order drugs. O how may occasios (i ay) have you: 56. used amphetamies, other tha methamphetamie, without a doctor tellig you to take them i your lietime? 57. used amphetamies, other tha methamphetamie, without a doctor tellig you to take them durig the past 30 days? Sedatives, icludig Barbiturates, are prescribed by doctors to help people relax or get to sleep. They are sometimes called dows or dowers, ad iclude pheobarbital, Tuial, Nembutal, ad Secoal. O how may occasios (i ay) have you: 58. used sedatives, without a doctor tellig you to take them, i your lietime? 59. used sedatives, without a doctor tellig you to take them, durig the past 30 days? Traquilizers are sometime prescribed by doctors to calm people dow, quite their erves, or relax their muscles. Librium, Valium, ad Xaax are all traquilizers. o how may occasios (i ay) have you: 60. take traquilizers, without a doctor tellig you to take them, i your lietime? 61. take traquilizers, without a doctor tellig you to take them, durig the past 30 days? 62. used heroi i your lietime? 63. used heroi durig the past 30 days? 5

OCCASIONS O how may occasios (i ay) have you: 0 1-2 3-5 6-9 10-19 20-39 40+ 64. take arcotics other tha heroi (such as methadoe, opium, morphie, codeie, Demerol, Vicodi, OxyCoti, ad Percocet) without a doctor tellig you to take them, i your lietime? 65. take arcotics other tha heroi (such as methadoe, opium, morphie, codeie, Demerol, Vicodi, OxyCoti, ad Percocet) without a doctor tellig you to take them, durig the past 30 days? 66. used MDMA (X, E, or ecstasy) i your lietime? 67. used MDMA (X, E, or ecstasy) durig the past 30 days? Steroids, or aabolic steroids, are sometimes prescribed by doctors to promote healig rom certai types o ijuries. Some athletes, ad others, have used them to try to icrease muscle developmet. O how may occasios (i ay) have you: 68. take steroids, without a doctor tellig you to take them, i your lietime? 69. take steroids, without a doctor tellig you to take them, durig the past 30 days? 70. Thik back over the last two weeks. How may times have you had ive or more alcoholic driks i a row? (A "drik" is a glass o wie, a bottle o beer, a wie cooler, a shot glass o liquor, a mixed drik, etc.) Noe Oce Twice 3-5 times 6-9 times 10 or more times The ext ew questios ask about your amily. Whe aswerig these questios please thik about the people you cosider to be your amily, or example, parets, stepparets, gradparets, auts, ucles, etc. No! o yes YES! 75. I you carried a hadgu without 71. Have you ever used smokeless tobacco (chew, su, your parets' permissio, would you be caught by your parets? plug, dippig tobacco, or chewig tobacco)? 76. I you skipped school would you Never Regularly i the past be caught by your parets? Oce or Twice Regularly ow Oce i a while but ot regularly 77. Do you eel very close to your mother? 72. How requetly have you used smokeless tobacco durig the past 30 days? 78. Do you share your thoughts ad eeligs with your mother? Never Three to ive times per week 79. My parets ask me what I thik beore most amily decisios aectig Oce or twice About oce a day me are made. Oce or twice per week More tha oce a day 80. Do you share your thoughts ad eeligs with your ather? 73. Have you ever smoked cigarettes? 81. Do you ejoy spedig time with your mother? Never Regularly i the past 82. Do you ejoy spedig time with Oce or Twice Regularly ow your ather? Oce i a while but ot regularly 83. I I had a persoal problem, I 74. How requetly have you smoked cigarettes durig the could ask my mom or dad or help. past 30 days? 84. Do you eel very close to your ather? Not at all 85. My parets give me lots o chaces to do u thigs with them. Less tha oe cigarette per day 86. My parets ask i I've gotte my Oe to ive cigarettes per day homework doe. About oe-hal pack per day 87. People i my amily have serious argumets. About oe pack per day 88. Would your parets kow i you About oe ad oe-hal packs per day did ot come home o time? Two packs or more per day 6

89. How wrog do your parets eel it would be or YOU to: a. drik beer, wie or hard liquor (or example, vodka, whiskey or gi) regularly? b. smoke cigarettes? Not wrog at all A little bit wrog Wrog Very wrog These questios ask about the eighborhood ad the commuity where you live. NO! o yes YES! 100. I I had to move, I would miss the eighborhood I ow live i. c. smoke marijuaa? d. steal somethig worth more tha $5? 101. My eighbors otice whe I am doig a good job ad let me kow about it. e. draw graiti, write thigs, or draw pictures o buildigs or other property (without the ower's permissio)?. pick a ight with someoe? 102. I like my eighborhood. 103. I'd like to get out o my eighborhood. 104. There are people i my eighborhood who are proud o me whe I do somethig well. 90. Have ay o your brothers or sisters I do't have ay brothers or sisters Yes No a. druk beer, wie or hard liquor (or example, vodka, whiskey or gi)? b. smoked marijuaa? c. smoked cigarettes? 105. There are people i my eighborhood who ecourage me to do my best. 106. Which o the ollowig activities or people your age are available i your commuity? a. sports teams No Yes b. scoutig No Yes c. boys ad girls clubs No Yes d. 4-H clubs No Yes e. service clubs No Yes 91. It is importat to be hoest with your parets, eve i they become upset or you get puished. 92. The rules i my amily are clear. 93. People i my amily ote isult or yell at each other. 94. Whe I am ot at home, oe o my parets kows where I am ad who I am with. NO! o yes YES! NO! o yes YES! 107. I a kid smoked marijuaa i your eighborhood would he or she be caught by the police? 108. I a kid drak some beer, wie or hard liquor (or example, vodka, whiskey, or gi) i your eighborhood would he or she be caught by the police? 109. I a kid carried a hadgu i your eighborhood would he or she be caught by the police? 95. We argue about the same thigs i my amily over ad over. 96. I you drak some beer or wie or liquor (or example, vodka, whiskey, or gi) without your parets' permissio, would you be caught by your parets? 97. My amily has clear rules about alcohol ad drug use. 110. I you wated to get some cigarettes, how easy would it be or you to get some? very easy sort o easy sort o hard very hard 98. How ote do your parets tell you they're proud o you or somethig you've doe? 111. I you wated to get some beer, wie or hard liquor (or example, vodka, whiskey, or gi), how easy would it be or you to get some? Never or Almost Never Ote 112. I you wated to get a drug like Sometimes All the Time cocaie, LSD, or amphetamies, how easy would it be or you to get some? 99. My parets otice whe I am doig a good job ad let me 113. I you wated to get some kow about it. marijuaa, how easy would it Never or Almost Never Ote be or you to get some? Sometimes All the Time 7

114. How wrog would most adults (over 21) i your eighborhood thik it is or kids your age: Not Wrog at All A Little Bit Wrog Wrog Very Wrog 118. About how may adults (over 21) have you kow persoally who i the past year have: Number o Adults 0 1 2 3-4 5+ a. to use marijuaa? a. used marijuaa, crack, cocaie, or other drugs? b. to drik alcohol? b. sold or dealt drugs? c. to smoke cigarettes? c. doe other thigs that could get them i trouble with the police, like stealig, sellig stole goods, muggig 115. How much does each o the ollowig statemets describe your eighborhood? or assaultig others, etc.? d. gotte druk or high? NO! o yes YES! 119. How hoest were you i illig out this survey? a. crime ad/or drug sellig b. ights c. lots o empty or abadoed buildigs I was very hoest I was hoest pretty much o the time I was hoest some o the time I was hoest oce i a while I was ot hoest at all d. lots o graiti Extra Questios Resposes a b c d e g h i 116. I the past year (12 moths), did you bet ay moey 120. or other thigs o value, o the results o a card game, sportig evet, lottery ticket, Iteret gamblig, video 121. poker, dice, race, bigo, or other games? 122. No Yes 123. 124. 40 or more days 117. Durig the past year (12 20-39 days 125. moths), o how may days 10-19 days (i ay) did you: 4-9 days 126. 2-3 days 127. 1 day Never 128. a. bet o card games (poker)? 129. b. bet usig Iteret gamblig sites? 130. c. bet o sportig evets? 131. d. buy lottery, scratch-o tickets? 132. e. bet o pool, bowlig, other games o 133. skill? 134.. bet o video poker, VLT's or other gamblig machies? 135. g. bet o dice games? 136. h. bet o bigo? 137. i. bet o horse racig? 138. j. bet at a casio? 139. Thak you or completig the survey 8