Drug and Alcohol Survey

The purpose of this survey is to gather information regarding students relationships

with drugs and alcohol at Catherine Blaine School. This is not a test and all answers
will be confidential, so please answer as honestly as you can. It should only take
about 10 minutes to complete.
Directions: Please read each answer carefully and fill in the circle next to the
answer that fits you the best. There are no right or wrong answers.
PLEASE CIRCLE
Age: 12
13 14
Gender: Male

Female

Other

Ethnicity (please circle):

Hispanic or Latino
Caucasian
Black or African American
Native Hawaiian or other Pacific Islander
Asian
American Indian or Alaska Native
Multiracial

1. Highest level of education completed by your parent/guardian (please circle):

Did not complete high school
High School/GED
Some College
Bachelors Degree
Masters Degree
Advanced Graduate work or Ph.D.
Not Sure

Please answer the following questions using the scale below:

0
1
2
3
Strongly Disagree
Disagree
Agree
Strongly Agree
1. I understand the effects of alcohol on my health
1
2
3
2. I understand the effects drugs may have on my health
1
2
3

0
0

3. I have the knowledge about what resources are available

2
3
regarding drugs and alcohol
4. My friends drink beverages containing alcohol

1
2
3
5. I feel pressure to drink alcohol

2
3
6. My friends use a substance to get high

2
3
7. I feel pressure to use drugs

2
3
8. A family member drinks alcohol in front of me
1
2
3
9. A family member uses drugs in front of me

0
0

2
3
10.The media understanding of drugs and alcohol is from the media 0

2
3
11.I feel comfortable talking about drugs and alcohol

with adults at my school

12.I know where drug and alcohol resources are available
1
2
3
13.The media (i.e. TV, movies, social media) affects the way
2

0
0

I feel about drugs and alcohol

14.How many days in the past year have you had more than a sip of beer wine
or any drink containing alcohol? (please circle):
0 times

1-2 times

3-5 times

5+ times

15.How many times in the past year have you used anything to get high in the
past year? (please circle):
0 times

1-2 times

3-5 times

5+ times

16.What would you like to know more about in relation to drugs and alcohol?
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17.Please explain why you use drugs and alcohol OR why you do not use drugs
and alcohol.
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