Form Pre- and Post-Yout Pre- and Post-Yout Pre- and Post-Youth Survey

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

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Student Pre-/Post-intervention Survey Instrument: Middle School XX

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 XXXX-XXXX, and it expires XX/XX/XXXX. 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 15E57B, Rockville, MD 20857.

XX Middle School is working with a federal agency to get your thoughts and opinions about issues pertaining to your health and well-being.

Please know that your responses will be confidential, which means no one, including teachers, your parents, or your friends, will know how you responded to the following questions. So please answer each question below as honestly as you can.

The information from this survey will help the agency create educational materials that can help you have a healthy and productive middle school experience.

Before you begin, we would like you to create a code for yourself. This code will help us to track your responses while keeping your information completely confidential.

Your teacher will lead you through the following code-building exercise:

Code-Building Exercise

Please enter the first letter of your legal first name ___________

Please enter the last letter of your legal first name ___________

Please enter the last letter of your legal last name ___________

Please enter the two-digit month you were born ___________

Please enter the two-digit DAY you were born ___________

Example: This is the information you would have recorded if your legal name were William Garcia- Lopez, born May 9: W_M_Z_05_09

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

No [Skip to Question 4]

Yes

2. Using your best estimate, 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. Using your best estimate, 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. How much, if at all, do YOU disapprove of your peers doing each of the following?

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

6. How much, if at all, do you think your peers risk harming themselves (physically or in other ways) if they...

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

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

No [Skip to Question 10]

Yes

8. When your parent or caregiver 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

If there are other things your parent or caregiver has said to you about alcohol and underage drinking, please share them here:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

9. Within the last 3 months, how often has your parent or caregiver 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

9b. IF YOUR PARENTS HAVE NOT TALKED TO YOU ABOUT ALCOHOL AND UNDERAGE DRINKING in the last 3 months, have they talked to you about it since the start of this school year?

• Yes

• No

10. Please mark your age below.

• 10 years old or younger

• 11 years old

• 12 years old

• 13 years old

• 14 years old

• 15 years old or older

11. Please mark your grade below.

• 6th grade

• 7th grade

• 8th grade

12. Please mark your gender below.

• Male

• Female

• Prefer not to say

Thank you for completing this survey!

We wish you a happy and successful end to the school year!

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