D-Fy Questionnaire CHAPTER _____________________ DATE____________________

New Member Renewing Member Random

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Drug-Free Youth Questionnaire

This survey will help us improve our program by asking you your opinion about the program and your behaviors. You will complete survey each time you renew or are called for a random re-test. The surveys will take about 20 minutes to complete. The surveys are anonymous and no one will be able to tell what you answered. A few of the questions ask about tobacco, alcohol, and drug use. Completing the survey, however, is voluntary and you may choose not to answer any or all of the questions but your answers will help us improve the program for you and for other youth. Whether or not you answer the questions or what you answer - will not affect your membership in Drug Free Youth and your individual answers will not be shared with anyone. If you have questions, contact Diane at 941.257.3019

1. What is your age? Please check one: 12 13 14 15 16 17 18 19 or older 2. School Grade 6 7 8 9 10 11

3. What is your gender? Please check one: Female Male 4. What is your race? Please check one: African American American Indian Asian Hispanic/Latino Native Hawaiian/Pacific Islander Other/Multiple White, non-Hispanic 5. Are you of Hispanic descent? Yes No

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6. Where did you hear about Drug Free Youth? Check all that apply: A friend or acquaintance told me I saw information about it at a business or restaurant I saw it on the Internet It was announced at school I saw a flyer or poster Other: __________________________________________

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76. How important if at all were the following in deciding to join Drug Free Youth? Very unimportant Discounts at businesses It is a requirement of another activity Im in It will help me get a job My friends are in it Social activities The membership card 8. Are there any other reasons you are choosing to join that we didnt list? Unimportant Neither unimportant or important Important Very important

9. How important - if at all - are the following to you? Very unimportant To be recognized for being drug free To have a way to meet people To know the community cares about us To know there are D-Fy members in other cities 10. Anything else that is important that about Drug Free Youth that we didnt list? Unimportant Neither unimportant or important Important Very important

11. In addition to the card, social activities, and discounts, is there anything else you would like to see offered as part of Drug Free Youth?

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12. Please choose the response that best reflects your opinion. NO! no My neighbors notice when I am doing a good job and let me know. There are people in my neighborhood who encourage me to do my best. There are people in my neighborhood who are proud of me when I do something well. 13. Please choose the response that best reflects your opinion Very wrong How wrong do you feel it would be for you or friends to drink beer, wine or hard liquor regularly? How wrong do you feel it would be for you or friends to smoke cigarettes? How wrong do you feel it would be for you or friends to smoke marijuana? How wrong you feel it would be for you or friends to smoke K-2, spice, incense or other synthetic marijuana? 14. Please choose the response that best reflects your opinion Very wrong How wrong do your parents feel it would be for you to drink beer, wine or hard liquor regularly? How wrong do your parents feel it would be for you to smoke cigarettes? How wrong do your parents feel it would be for you to smoke marijuana? How wrong do your parents feel it would be for you to smoke K-2, spice, incense or other synthetic marijuana? 15. Think of your four best friends (the friends you feel closest to). In the past 12 months, how many of your best friends have: None Smoked cigarettes? Tried beer, wine or hard liquor when their parents didn't know about it? Used marijuana? Used K-2, spice, incense or other synthetic marijuana Used any other drug without a doctors orders? 1 friend 2 friends 3 friends 4 friends Wrong A little bit wrong Not wrong at all Wrong A little bit wrong Not wrong at all yes YES!

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16. Select the response that best describes your answer. This question asks about your behavior over the past 30 days. Never Once or twice Once or twice per week About once a day More than once a day

On how many occasions (if any) have you used tobacco (cigarette, cigar, or smokeless) in the past 30 days? On how many occasions (if any) have you had beer, wine or hard liquor during the past 30 days? On how many occasions (if any) have you used marijuana or hashish during the past 30 days? On how many occasions (if any) have you used K-2, spice, incense or other synthetic marijuana during the past 30 days? On how many occasions (if any) have you used any other drug without a doctor's orders during the past 30 days?

17. Select the response that best describes your answer. This question asks about your behavior during your lifetime. 0 times During your life, how many times have you used tobacco (cigarette, cigar, or smokeless)? During your life, how many times (if any) have you had beer, wine or hard liquor? During your life, how many times have you used marijuana or hashish? During your life, how many times have you used K-2, spice, incense or other synthetic marijuana? During your life, how many times have you used any other drug without a doctor's orders? 1-3 times 39 times 10 to 19 times 20 to 39 times 40 or more times

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