Youth Substance Use and Abuse Survey
2017-2018 DATA COLLECTION
AGE? *
GENDER: *
ZIP CODE *
Your answer
WHAT SUBSTANCE HAVE YOU USED IN YOUR LIFETIME? (Check all that apply) *
Required
HOW OFTEN DO YOU USE THIS SUBSTANCE? *
ONCE A MONTH
TWICE A MONTH
ONCE A WEEK
SEVERAL TIMES A WEEK
DAILY
SOMETIMES
NEVER
ALCOHOL
MARIJUANA
OPIOID PRESCRIPTION DRUGS
COCCAINE
HEROIN
WHERE DID YOU GET THE SUBSTANCE FROM? (Check all that apply) *
HOME
RELATIVE
FRIEND
PERSONAL PURCHASE
STRANGER
DOCTOR
N/A
ALCOHOL
MARIJUANA
OPIOID PRESCRIPTION DRUGS
COCCAINE
HEROIN
PRESCRIPTION DRUGS *
YES
NO
NOT SURE
Do you think that taking prescription drugs that were not prescribed for you is wrong or harmful?
Do your friends think that taking prescription medication that is not meant for you is wrong or harmful?
Do your parents think that taking prescription medication that is not meant for you is wrong or harmful?
DO YOU THINK... *
OK TO DO
OK TO DO SOMETIMES
NOT OK TO DO
HARMFUL
NOT HARMFUL
Marijuana is:
Alcohol is:
Cocaine is:
Heroin is:
WHAT ABOUT.... *
OK TO DO
OK TO DO SOMETIMES
NOT OK TO DO
HARMFUL
NOT HARMFUL
Your Friends, do they think that Marijuana is:
Your Friends, do they think Alcohol is:
Your Parents, do they think Marijuana is:
Your Parents, do they think Alcohol is:
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