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Core Alcohol and Drug Survey Form 194 Core Alcohol and Drug Survey For additional use: Long Form A 0 1 2 3 4 5 6 7 8 9 B 0 1 2 3 4 5 6 7 8 9 FIPSE Core Analysis Grantee Group Core Institute C 0 1 2 3 4 5 6 7 8 9 Student Health Programs 0 1 2 3 4 5 6 7 8 9 Southern Illinois University D Please use a number 2 Pencil. Carbondale, IL 62901 E 0 1 2 3 4 5 6 7 8 9 1. Classification: 2. Age: 3. Ethnic origin: 4. Marital status: Freshman . American Indian/ Single . Sophomore . Alaskan Native . Married . Junior . 0 0 Hispanic . Separated . Senior. 1 1 Asian/Pacific Islander . Divorced. Grad/professional . 2 2 White (non-Hispanic) . Widowed . Not seeking a 3 3 Black (non-Hispanic) . degree . 4 4 Other . 7. Are you working? Other . 5 5 Ye s, full-time . 6 6 6. Is your current residence Ye s, part-time . 5. Gender: 7 7 as a student: No . Male . 8 8 On-campus . Female . 9 9 Off-campus . 8. Living arrangements: A. Where: (mark best answer) 9. Approximate cumulative grade point average: (choose one) House/apartment/etc. Residence hall . A+AA- B+BB- C+CC- D+DD-F Approved housing. Fraternity or sorority . 10. Some students have indicated that alcohol or drug use at parties they attend in and Other . around campus reduces their enjoyment, often leads to negative situations, and therefore, they would rather not have alcohol and drugs available and used. Other B. With whom: students have indicated that alcohol and drug use at parties increases their (mark all that apply) enjoyment, often leads to positive situations, and therefore, they would rather have With roommate(s). alcohol and drugs available and used. Which of these is closest to your own view? Alone . Have available Not have available With parent(s) . With regard to drugs? . With spouse . With regard to alcohol?. With children . Other . 11.Student status: 12. Campus situation on alcohol and drugs: yesnodon’t know Full-time (12+ credits) . a. Does your campus have alcohol and drug policies? . Part-time (1–11 credits) . b. If so, are they enforced? . .. c. Does your campus have a drug and alcohol 13.Place of permanent prevention program? . .. residence: d. Do you believe your campus is concerned about In-state . the prevention of drug and alcohol use? . USA, but out of state . e. Are you actively involved in efforts to prevent drug Country other than USA . and alcohol use problems on your campus? . Did not use 14. Think back over the last 15.Average # of 16. At what age did you Under 10 10–11 two weeks. How many drinks* you first use… 12–13 14–15 16–17 18–20 21–25 26+ times have you had consume a week: (mark one for each line) five or more drinks* a.Tobacco (smoke, chew, snuff) . at a sitting? b. Alcohol (beer, wine, liquor)* . None . 0 0 c. Marijuana (pot, hash, hash oil) . (If less than Once . 1 1 d. Cocaine (crack, rock, freebase) . 10, code Twice . 2 2 e. Amphetamines (diet pills, speed) . answers as 3 to 5 times . 3 3 f. Sedatives (downers, ludes) . 00, 01, 02, 6 to 9 times . 4 4 g. Hallucinogens (LSD, PCP). etc.) 10 or more times . 5 5 h. Opiates (heroin, smack, horse). 6 6 i. Inhalants (glue, solvents, gas) . *A drink is a bottle of beer, a glass 7 7 j. Designer drugs (ecstasy, MDMA) . of wine, a wine cooler, a shot glass 8 8 k. Steroids . of liquor, or a mixed drink. 9 9 l. Other illegal drugs . *Other than a few sips © Core Institute: 1989, 1990, 1991, 1992, 1993, 1994. 17.Within the last year 3 times/w 5 times/w 18.During the past 30 days 6 times/y Once/monthT Did not use wice/monthOnce/w 10–19 da 20–29 da Once/y All 30 da Ev about how often have on how many days 1–2 da 3–5 da 6–9 da er 0 da you used… y da did you have: ear ear eek eek eek ys ys ys ys ys ys ys (mark one for each line) y (mark one for each line) a.Tobacco (smoke, chew, snuff) . a.Tobacco (smoke, chew, snuff) . b. Alcohol (beer, wine, liquor) . b. Alcohol (beer, wine, liquor) . c. Marijuana (pot, hash, hash oil). c. Marijuana (pot, hash, hash oil) . d. Cocaine (crack, rock, freebase) d. Cocaine (crack, rock, freebase) . e. Amphetamines (diet pills, speed) e. Amphetamines (diet pills, speed) . f. Sedatives (downers, ludes) . f. Sedatives (downers, ludes) . g. Hallucinogens (LSD, PCP) . g. Hallucinogens (LSD, PCP). h. Opiates (heroin, smack, horse) h. Opiates (heroin, smack, horse). i. Inhalants (glue, solvents, gas) . i. Inhalants (glue, solvents, gas) . j. Designer drugs (ecstasy, MDMA) j. Designer drugs (ecstasy, MDMA) . k. Steroids . k. Steroids . l. Other illegal drugs . l. Other illegal drugs . 19.How often do you 3 times/w 5 times/w 21.Please indicate how often 6 times/y Once/monthT wice/monthOnce/w Once/y think the average student Ev you have experienced 10 or more times er Ne on your campus uses… y da the following due to ver ear ear eek eek eek 3–5 times (mark one for each line) y your drinking or drug use 6–9 times Ne Once T a.Tobacco (smoke, chew, snuff) . during the last year… wice v b. Alcohol (beer, wine, liquor) . (mark one for each line) er c. Marijuana (pot, hash, hash oil). a. Had a hangover . d. Cocaine (crack, rock, freebase) b.P erformed poorly on a test e. Amphetamines (diet pills, speed) or important project . f. Sedatives (downers, ludes) . c. Been in trouble with police, g. Hallucinogens (LSD, PCP) . residence hall, or other h. Opiates (heroin, smack, horse) college authorities . i. Inhalants (glue, solvents, gas) . d. Damaged property, pulled j. Designer drugs (ecstasy, MDMA) fire alarm, etc. k. Steroids . e. Got into an argument or fight . l. Other illegal drugs . f. Got nauseated or vomited . g. Driven a car while under the influence . On campus e h. Missed a class . Where y 20. Where have you Residence hall Bar/restaur Pr F ivate par i. Been criticized by someone Ne r at/soror used… ver used In a car I know . ou live (mark all that apply) vents Other j. Thought I might have a drinking ant ties ity or other drug problem . a.Tobacco (smoke, chew, snuff) . k. Had a memory loss . b. Alcohol (beer, wine, liquor) . l. Done something I later regretted . c. Marijuana (pot, hash, hash oil). m. Been arrested for DWI/DUI. d. Cocaine (crack, rock, freebase) n. Have been taken advantage e. Amphetamines (diet pills, speed) of sexually . f. Sedatives (downers, ludes) . o. Have taken advantage of g. Hallucinogens (LSD, PCP) . another sexually . h. Opiates (heroin, smack, horse) p. Tr ied unsuccessfully to stop using. i. Inhalants (glue, solvents, gas) . q. Seriously thought about suicide. j. Designer drugs (ecstasy, MDMA) r. Seriously tried to commit suicide . k. Steroids . s. Been hurt or injured. l. Other illegal drugs . 23. If you volunteer any of your time on or off campus 22. Have any of your family had alcohol or other to help others, please indicate the approximate drug problems: (mark all that apply) number of hours per month and principal activity: Mother Brothers/sisters Spouse Don’t volunteer, or 10–15 hours Father Mother’s parents Children less than 1 hour 16 or more hours Stepmother Father’s parents None 1–4 hours Principal volunteer activity is: Stepfather Aunts/uncles 5–9 hours 24.Within the last year to 27. Do you believe that alcohol has what extent have you Activ the following effects? e in participated in any of the Not in (mark one for each line) non-leaderv Leadership following activities? Attended olv yesno position v ement, (mark one for each line) olv a. Breaks the ice . ed b. Enhances social activity . a. Intercollegiate athletics . n/a c. Makes it easier to deal with stress . b. Intramural or club sports. n/a d.Facilitates a connection with peers . c. Social fraternities or sororities . e. Gives people something to talk about . d. Religious and interfaith groups . f.F acilitates male bonding. e. International and language groups . g.Facilitates female bonding . f. Minority and ethnic organizations . h. Allows people to have more fun . g.Political and social action groups . i. Gives people something to do . h. Music and other performing j. Makes food taste better . arts groups . k. Makes women sexier . i. Student newspaper, radio, TV, l. Makes men sexier . magazine, etc. m. Makes me sexier . n.Facilitates sexual opportunities . 25.In the first column, indicate whether any of the following have happened to you within the last year while you were 28.On this campus, drinking is a central in and around campus. alcohol or drugs part in the social life of the following If you answered yes to groups: Consumed any of these items, indicate Happened (mark one for each line) in the second column if you yesno to y had consumed alcohol or a. Male students . other drugs shortly before ou b.F emale students . these incidents. c.Faculty/staff . yes no yes no d. Alumni . a. Ethnic or racial harassment . e. Athletes. b. Threats of physical violence. f. Fraternities . c. Actual physical violence . g. Sororities . d. Theft involving force or threat If of force . yes 29.Campus environment: (mark one for each line) e.F orced sexual touching or fondling . a. Does the social atmosphere on this yesno f.
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