Assent Form for Students

Dear respondent,

My name is Cate Nandawula, a student of Social Sciences majoring in Psychology of Makerere

University. This form is meant to seek for your assent before you take part in this study which

will be used for academic research purposes only. My topic is: “Drug abuse, school dropout and

juvenile delinquency among adolescents in Mengo”. You have been randomly selected to

participate in this study.

I------------------------ of ----------------------- agree to participate in this study and I understand

that my participation is voluntary. I am aware that I have a right to withdraw from the exercise at

any time if I feel that I am not comfortable without being asked to give a reason.

By signing below I am indicating my assent to participate in this study and I understand that the

data collected from my participation will be used primarily for a bachelor’s degree dissertation. I

consent for it to be used in that manner.

Signature of respondent ---------------------------------

SECTION A

Questionnaire: Demographic information

Age of the student: a) 11yrs-13yr ………b) 14yrs-16yrs ………c) 17yrs-18yrs………...

Class: ………………………………………………..

Sex; a) Male………………………… b) Female …………………………..

Religion: a) Christian……. b) Muslim…… c) Other……

SECTION B: Substance Abuse Questionnaire

The following questions concern information about your potential involvement with substances

like alcohol, tobacco, etc. Carefully read each statement and tick in the table using the scale

below (SAS-National Drug Authority Uganda, 2013).

1 2 3 4 5
Never Rarely Sometimes Frequently Always

How often do you do or experience the following:- Responses

1. Taking some drinks which contained alcohol. 1 2 3 4 5
2. Spending a week without taking some alcohol 1 2 3 4 5
3. Smoking cigarettes whenever you are bored 1 2 3 4 5
4. Getting "blackouts" as a result of too much alcohol 1 2 3 4 5
5. Chewing tobacco 1 2 3 4 5
6. My parents complaining about my involvement with alcohol and tobacco 1 2 3 4 5
7. Getting in trouble with my parents because of drinking alcohol 1 2 3 4 5
8. Taking different types of alcoholic drinks in one day 1 2 3 4 5
9. Losing friends because of my substance abuse (alcohol, tobacco) 1 2 3 4 5
10.Taking alcohol to feel more relaxed 1 2 3 4 5
11. Getting in trouble at school because of alcohol or tobacco use 1 2 3 4 5
 12. Avoiding social situations like parties because there is alcohol. 1 2 3 4 5
13. Getting involved in a fight when under the influence of alcohol 1 2 3 4 5
14. Engaging in risky activities in order to obtain alcohol / tobacco 1 2 3 4 5
15. Feeling comfortable with a friend who drinks alcohol or smokes tobacco 1 2 3 4 5
16. Getting sick because of smoking too much tobacco 1 2 3 4 5
17. Having health problems as a result of substance abuse 1 2 3 4 5
18. Drinking alcohol at social functions like Parties 1 2 3 4 5
19. Getting convinced that substance use (alcohol, tobacco) is the root cause 1 2 3 4 5
of many problems among students
20.Using more than one substance at a time ( tobacco, alcohol) 1 2 3 4 5
21. Taking alcohol to feel less shy 1 2 3 4 5

SECTION C: Risk to School dropout

Read each of the following statements and decide how much you agree or disagree with them.

Strongly Disagree Neutral Agree Strongly

Disagree Agree
I work hard at school 1 2 3 4 5
It's important to me that I improve 1 2 3 4 5
my skills this year
I concentrate on my schoolwork 1 2 3 4 5
I feel proud of my school 1 2 3 4 5
I am a responsible student 1 2 3 4 5
I am treated with as much respect 1 2 3 4 5
as other students
I complete my schoolwork 1 2 3 4 5
regularly
In my school I feel that I belong to 1 2 3 4 5
a group of friends
I take responsibility for working on 1 2 3 4 5
my goals
There's at least one adult in this 1 2 3 4 5
school I can talk to if I have a
problem
I am good at staying focused on 1 2 3 4 5
my goals
I am comfortable asking my 1 2 3 4 5
teacher(s) for help
I know I will graduate from high 1 2 3 4 5
school
I have a plan for what I want to 1 2 3 4 5
do after high
I am hopeful about my future 1 2 3 4 5
I work well in a group or team 1 2 3 4 5
I can resist doing something when 1 2 3 4 5
I know I shouldn't do it
It is easy for me to 1 2 3 4 5
communicate my thoughts
and ideas
I can discuss a 1 2 3 4 5
problem with a friend without
making it worse
I am a hard worker 1 2 3 4 5
I finish whatever I 1 2 3 4 5
begin
I can do almost all the work in 1 2 3 4 5
class
I can learn the things taught in 1 2 3 4 5
school
What we do in school will help 1 2 3 4 5
me succeed in life
I try things even if I might 1 2 3 4 5
fail.