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The American Drug and Alcohol Survey

The American Drug and Alcohol Survey

Important Directions for Marking Answers THE AMERICAN ¥ Use #2 pencil only. Right ¥ Do NOT use ink or ballpoint pens. AND SURVEY ™ Wrong ✗ ¥ Make heavy black marks that fill the circle completely. ¥ Erase cleanly any answer you wish to change. Wrong ✓ DO NOT PUT YOUR NAME ON THIS SURVEY ¥ Make no stray marks on the answer sheet. Wrong 1. What grade are you in?

56789101112College 13. In using alcohol, are you a. . .

2. How old are you? Non Very Light Mod- Heavy Very user light user erate user heavy user User user 10 11 12 13 14 15 16 1718 19 20 21 or older 14. Has your drinking alcohol ever caused you any of the 3. Sex: Male Female following problems? 10 or 1-2 3-9 more No times times times 4. Have you ever had alcohol to Get a traffic ticket? drink-more than a few sips? Yes No Have a crash? Get arrested? 5. Have you ever gotten drunk? Yes No Have money problems? Gotten you in trouble at school? 6. How old were you the first time you got drunk? Hurt your school work? Never gotten drunk Fight with other kids? Fight with your parents? 7 or 8 9 10 11 12 13 14 15 16 17 18 19 or Damaged a friendship? younger older Passed out? Couldn’t remember what 7. How often in the last 12 months have you. . . happened while drinking? 50 or Made you something? 1-2 3-9 10-19 20-49 more None times times times times times Did something sexual that you Had alcohol to drink later wished you hadn't? Gotten drunk Hurt yourself? Hurt someone else? 8. How often in the last month have you. . . 20 or 15. During the last 12 months, where have you used 1-2 3-9 10-19 more None times times times times alcohol? 10 or 1-2 3-9 more Had alcohol to drink Never times times times Gotten drunk At weekend parties At night with friends 9. How do you like to drink? Before school events I don’t drink Enough to feel it a lot At school events Just a glass or two Until I get really drunk (dances, games, etc.) Enough to feel it a little After school events On the way to school 10. How much would your friends try to stop you from During school hours at school getting drunk? During school hours away A lot Some Not much Not at all from school Right after school 11. How often have your friends asked you to get drunk? While driving around A lot Some Not much Not at all At home (parents knew) At home (parents didn’t know) 12. How much do you think people harm themselves (physically or otherwise) if they. . . 16. How many of your friends. . . One Some Most or of of Very A lot None two them them No little Some of harm harm harm harm Get drunk once in a while Use alcohol 1 or 2 times Get drunk almost every weekend Use alcohol regularly Get drunk 1 or 2 times 17. Have you ever tried marijuana (pot, grass, hash, etc.)? Get drunk regularly Yes No

Copyright 1999 by RMBSI, Inc., P.O. Box 1066, Ft. Collins, CO 80522. All rights reserved. Form A12 18. How have you used marijuana? (Mark all that are right.) 27. Have you used any of the following just to I have not used it Used a "bong" or other equipment get high or taken an extra dose just to get high Smoked it Used sinsemilla during the last 12 months? 50 or 1-2 3-9 10-19 20-49 more Eaten it Used (hash) No times times times times times Smoked "blunts" Tranquilizers Downers 19. How old were you the first time you tried marijuana? Ritalin Never used 28. Have you used any of the following drugs just to get 7 or 8 9 10 11 12 13 14 15 16 17 18 19 or high or taken an extra dose just to get high during younger older the last month? 1-2 3-9 10-19 20 or more No times times times times 20. How often in the last 12 months have you used Tranquilizers marijuana? Downers Ritalin None 1-2 3-9 10-19 20-49 50 or times times times times more times 29. In some states you can buy legal that are supposed to act like speed (, , etc.). 21. How often in the last month have you used marijuana? Have you tried any legal stimulants? Yes No None 1-2 3-9 10-19 20 or Several times times times more times every times day 30. Have you used any legal stimulants (ephedrine, ephedra, etc.) in the last 12 months? 22. In using marijuana are you a. . . No 1-2 3-9 10-19 20-49 50 or more times times times times times Non Very Light Mod- Heavy Very User Light User erate User Heavy User User User 31. Have you ever used a other than to get high (, Demerol, , Talwin, , 23. Have you ever “sniffed” (or “huffed”) glue, , sprays, )? or anything like that to get high? (Do NOT include Yes No .) Yes No 32. Have you ever used steroids to try to increase your strength or improve how your body looks? 24. How old were you the first time you “sniffed” (or Yes No “huffed”) glue, gas, sprays, or anything like that to get high? (Do NOT include cocaine.) 33. During the last 12 months, how many times have you Never used used steroids to increase your strength or improve how your body looks? 7 or 8 9 10 11 12 13 14 15 16 17 18 19 or younger older None 1-2 3-9 10-19 20-49 50 or more times times times times times

25. Have you ever been given any of the following drugs 34. Have you ever tried any of the following drugs? by a doctor for medicine? Yes No Yes No (uppers, bennies, speed, Tranquilizers (Valium, Librium, etc.) etc. Do NOT include legal stimulants) (downers, , Cocaine Seconal, etc.) Crack (rock, smoke cocaine) Ritalin “Sniff” something like glue, gasoline, etc. LSD (acid) 26. Have you used any of the following drugs to get high Other psychedelic (, or taken extra doses just to get high? , mushrooms, etc.) Yes No PCP Tranquilizers (Valium, Librium, etc.) ("Special K") Downers (barbiturates, Phenobarbital, Heroin Seconal, reds, yellows, etc.) Adrenochromes (spinners, Bovays) Ritalin (Crystal meth, ice, crank) Ecstasy (“XTC,” MDMA) GHB or GBH Rohypnol (Roofies, ruffies, etc.)

THANK YOU FOR COMPLETING THIS SURVEY 35. Have you used any of these drugs to get high during 41. During the last 12 months, where have you used the last 12 months? 50 or marijuana or any other illegal drug (except alcohol)? 1-2 3-9 10-19 20-49 more None times times times times times 10 or 1-2 3-9 more Uppers Never times times times Cocaine At weekend parties Crack At night with friends “Sniff” something like Before school events glue, gasoline, etc. At school events LSD (acid) (dances, games, etc.) Other psychedelic After school events PCP On the way to school Ketamine ("Special K") During school hours at school Heroin During school hours away Other (Codeine, from school Demerol, etc.) Right after school Adrenochromes (Bovays) While driving around Methamphetamines At home (parents knew) Ecstasy (“XTC,” MDMA) At home (parents didn't know)

36. Have you used any of these drugs to get high during the last month? 20 or 42. In using each of the following, are you a. . . 1-2 3-9 10-19 more No times times times times Very Mod- Very Non light Light erate Heavy heavy Uppers user user user user user user Cocaine Uppers “Sniff” something like “Sniff” something glue, gasoline, etc. like glue or gas LSD (acid) LSD (acid) Other psychedelic Other PCP psychedelics Ketamine ("Special K") Downers Heroin PCP Other narcotics Heroin Adrenochromes (Bovays) Steroids Methamphetamines Cigarettes Ecstasy (“XTC,” MDMA) Smokeless 37. Have you ever used. . . Yes No Cigarettes (, snuff, etc.) cigars or little cigars 43. Have you ever. . . Yes No Gotten drunk when alone? 38. In the last month have you. . . Yes No Used marijuana when alone? Smoked cigarettes Used another drug when alone? Used smokeless tobacco Used a needle to take steroids? Used a needle to take any drug to get high? 39. Do you smoke cigarettes? Shared a needle? Stayed high more than seven hours? Not Once 1-5 Half A pack Used (laughing gas) to get high? at in a times a pack or more all while a day a day a day Used amyl, ethyl, or butyl nitrites (, snappers, 'rush', etc.) 40. Do you use smokeless tobacco (chewing tobacco, Used Quaaludes (ludes, soapers, quacks) snuff, etc.)?

Not Once 1-5 6-10 Almost at in a times times all all while a day a day the time

THANK YOU FOR COMPLETING THIS SURVEY 44. How easy do you think it would be for you to get each 50. Has your use of marijuana or other drugs ever caused of the following types of drugs if you wanted some? you to have any of the following problems? 10 or Very Fairly Very Probably 1-2 3-9 more Easy Easy Hard Hard Impossible No times times times Alcohol Get a traffic ticket? Marijuana Have a car crash? Uppers Get arrested? Cocaine Have money problems? “Sniff” glue or gas, etc. Gotten you in trouble at school? LSD (acid) Hurt your school work? Other psychedelic Fight with other kids? Downers Fight with your parents? PCP Damaged a friendship? Heroin Have a “bad trip”? Other narcotic Made you break something? Cigarettes Did something sexual that you later wished you hadn't? 45. How much would your friends try to stop you from. . . Hurt yourself? A Not Not lot Some much at all Hurt someone else? Using marijuana 51. How much do you think people harm themselves Using cocaine if they. . . “Sniffing” glue or gas, etc. Very A lot I No little Some of don’t Using uppers harm harm harm harm know Using downers Use marijuana 1-2 times cigarettes Use marijuana regularly Use cocaine 1-2 times 46. How much would you try to stop your friends from. . . Use cocaine regularly A Not Not lot Some much at all “Sniff” 1-2 times Using marijuana “Sniff” inhalants regularly Using cocaine Use uppers 1-2 times “Sniffing” glue or gas, etc. Use uppers regularly Using uppers Use LSD (acid) 1-2 times Using downers Use LSD (acid) regularly Getting drunk Use tobacco occasionally Smoking cigarettes Use tobacco regularly Use meth 1-2 times 47. How many of your friends do each of the following. . . Use meth regularly A Most of All None few them of them 52. Are you. . . Use marijuana White Alaska Native Puerto Rican Use cocaine Black or African Asian American American “Sniff” glue or gas, etc. American Mexican American Other Use uppers American Indian Spanish American Use downers Get drunk 53. When I answered the questions about alcohol. . . Smoke cigarettes I was very honest I said I used it more than I really do 48. How often have your friends asked you to use. . . I said I used it less than I really do Very Not Very Not Often Some Often at all Marijuana 54. When I answered the questions about drugs. . . Cocaine I was very honest “Sniff” glue or gas, etc. I said I used them more than I really do Uppers I said I used them less than I really do Downers Cigarettes 55. Which of the statements below best describes your drug use? (Do NOT count alcohol use for this question.) 49. Have you ever done any of the following things? I have. . . Used alcohol and marijuana together Yes No never used drugs and never will. Used alcohol and another drug together Yes No never used drugs, but may in the future. used drugs, but don’t plan to use them again. used drugs, and probably will use them again.

Mark Reflex¨ by NCS MM103292-5 654321 Printed in U.S.A.

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