Please feel free to write any comments, constructive criticism, or questions below:

THANK YOU FOR YOUR TIME!

Student In-Class Survey

Directions: Please read each question carefully and check the answer that best fits for
you. Remember, please be honest with your answers and all answers are anonymous.
1) What grade level are you in?
__ 9
th
__ 10
th
__ 11
th
__ 12
th

2) What gender do you identify as? __ Male __ Female __ Other __Prefer Not to
Answer
3) What is your ethnicity/race (Check all that applies)?
__ White/Caucasian __ Black/African-American __ Asian/Pacific Islander
__ Amer. Indian/Native American __ Hispanic/Latino __ Two or More Races
_________Other

4) What grade marks do you typically earn? __A/Bs __ B/Cs __C/Ds __D/Es

5) Are you TARDY, UNEXCUSED LATE or, ABSENT to 1 or more classes a
week? If so... __ Yes __ No
What class period(s) is it (Check all that applies)?
__1
st
Period __4/5
th
Period Before Lunch __4/5
th
Period After-Lunch __Other
6) Do you smoke marijuana? __ Yes __ No
A. If you do not smoke Marijuana
i. Have you ever tried marijuana in the past? ___ Yes ___ No
Why do you choose not to use it now? _____________
____________________________________________
ii. If you never have Why do you choose not to use it? ______
_____________________________________________

B. If you do smoke Marijuana Why do you choose to use it? _______
________________________________________________________
****Please circle all that applies to each item.
B.1) In a typical week,
how often do you
SMOKE marijuana?
Once a
month
Twice a
month
Once a
Week
Once a
day
More than
once a day
B.2) What time of the
day do you typically
smoke marijuana?
4AM to
8AM
8AM to
3PM
3PM to
8PM
8PM to
12PM
12PM to
4AM

B.3) What day(s) do
you usually SMOKE
Mon Tues Wed Thurs Fri Sat Sun
Please feel free to write any comments, constructive criticism, or questions below:
THANK YOU FOR YOUR TIME!


marijuana?