Form A - Healthy Youth Survey - 2012 (Page 7 of 16) in pdf

E. Not counting alcohol, tobacco, or marijuana,

57. Does your school provide a counselor,

use another illegal drug?

intervention specialist, or other school staff

a. None

member for students to discuss problems with

b. 1 – 2 days

alcohol, tobacco, or other drugs?

c. 3 – 5 days

a. No

d. 6 – 9 days

b. Yes

e. 10 or more days

c. I’m not sure

F. Use derbisol (wagon wheels, hope)?

58. My school will punish students who are caught

a. None

using alcohol or drugs.

b. 1 – 2 days

a. NO!

c. 3 – 5 days

b. no

d. 6 – 9 days

c. yes

e. 10 or more days

d. YES!

G. Use a pain killer TO GET HIGH, like Vicodin,

OxyContin (sometimes called Oxy or OC) or

This section asks other questions about alcohol and

Percocet (sometimes called Percs)?

tobacco.

a. None

b. 1 – 2 days

c. 3 – 5 days

59. Think back over the last 2 weeks. How many

d. 6 – 9 days

times have you had five or more drinks in a row?

e. 10 or more days

(A drink is a glass of wine, a bottle of beer, a shot

glass of liquor, or a mixed drink.)

54. Some kids take a medicine prescribed by their

a. None

doctor to help with hyperactivity or focus

b. Once

(ADD). Some names for this medicine are Ritalin,

c. Twice

Adderall, or Concerta. In the past 30 days have

d. 3 – 5 times

you taken one of these drugs?

e. 6 – 9 times

a. No

f. 10 or more times

b. Yes, prescribed by my doctor for me

c. Yes, but NOT prescribed by a doctor for me

60. How many times in the past year (12 months)

have you been drunk or high at school?

55. If you have EVER used pain killers to get high,

a. Never

where did you usually get them?

b. 1 – 2 times

a. I did not use pain killers to get high

c. 3 – 5 times

b. I used my own prescription (from a doctor or

d. 6 – 9 times

dentist)

e. 10 or more times

c. A family member gave them to me

d. I took them from my home or someone else’s

61. During the past 30 days, how did you get alcohol

home without permission

(beer, wine, or hard liquor)? Choose all that

e. I got them from a friend

apply.

f. I got them from an acquaintance

a. I did not get alcohol in the past 30 days

g. I got them from a drug dealer

b. I bought it from a store

h. I got them from the internet

c. I got it from friends

i. I got them some other way

d. I got it at a party

e. I got it from an older brother or sister

56. During the last year, have you felt that you

f. I gave money to someone to get it for me

needed help (such as counseling or treatment) for

g. I took it from home without my parents’

your alcohol, tobacco, or other drug use?

permission

a. I have not used alcohol or other drugs

h. I got it at home with my parents’ permission

b. I have used alcohol and/or drugs, but I haven’t

i. I got it at a family celebration, ceremony, or

needed help

party

c. Yes, I felt I have needed help

j. I got it some other way

d. Not sure

Form A - Healthy Youth Survey - 2012 Page 7

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