Form Youth Pre-test Pos Youth Pre-test Pos Youth Pre-test Post-test Survey

Attachment 3: Youth Pre-Test and Post-Test Survey

OMB Control Number:  ______

Expires: ________

Logo for SAMHSA and CSAP

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is ____, expires: _____.  Public reporting burden for this collection of information is estimated to average 10 minutes per respondent, including the time for reviewing instructions.  Send comments regarding this burden to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 16E89B, Rockville, MD  20857.

Underage Drinking Attitudes and Behaviors Survey

We want to ask you questions about drinking alcoholic beverages, including beer, wine, liquor and any other beverage that contains alcohol. Please answer each question below honestly. Your responses will be kept confidential and will not be associated with your identity.

1. Have you ever had any alcoholic beverage to drink—more than just a few sips?

No [Skip to Question 4]

Yes

2. On how many occasions (if any) have you had alcoholic beverages to drink—more than just a few sips...

	0	1-2	3-5	6-9	10-19	20-39	40 or more
In your lifetime?
During the last 12 months?
During the last 30 days?

3. On how many occasions (if any) have you been drunk or very high from drinking alcoholic beverages...

	0	1-2	3-5	6-9	10-19	20-39	40 or more
In your lifetime?
During the last 12 months?
During the last 30 days?

4. How much pressure do you feel from your friends and schoolmates to drink alcoholic beverages?

None A Little

Some A Lot

5. Do YOU disapprove of people doing each of the following?

	Don't Disapprove	Disapprove	Strongly Disapprove	Can't Say
Trying one or two drinks of an alcoholic beverage (beer, wine, liquor)
Taking one or two drinks nearly every day
Having five or more drinks once or twice each weekend

6. How much do you think people risk harming themselves (physically or in other ways) if they...

	No Risk	Slight Risk	Moderate Risk	Great Risk	Can't Say
Try one or two drinks of an alcoholic beverage (beer, wine, liquor)?
Take one or two drinks nearly every day?
Have five or more drinks once or twice each weekend?

7. Has your parent or guardian ever had a conversation with you about the dangers of drinking alcohol?

No [Skip to question 10]

Yes

8. When your parent or guardian talked to you about the dangers of drinking alcohol, what did he or she say? Check all that apply.

Underage drinking is not acceptable I want you to be happy and safe I know about alcohol and can be counted on to answer your questions

I will know if you drink I can help you figure out ways to avoid drinking Underage drinking can have serious consequences None of the above

9. Within the last 3 months, how often has your parent or guardian talked to you about the dangers of drinking alcohol?

Once Twice Three times

Four times Five times or more Not at all in the last 3 months

10. How old are you?

9-10 year old 11-12 years old

13-14 years old 15 years or older

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