Exhibit A_Survey Example.pdf
PDF 951 KB Posted
- Attached to
- Assessment and Evaluation Services
- Solicitation number
- 624
- Issued by
- Idaho
About this file
This file is a Youth Survey instrument for Grades 6-12 designed for the Idaho Office of Drug Policy's grant programs. The survey serves as a pre- and post-program assessment tool for mandatory program use, with optional applications available for other programs. The instrument is administered to youth participants in grades 6 through 12 and collects baseline and outcome data to evaluate program effectiveness across initiatives funded through PFS, SUPTRS, ARPA, Opioid Settlement Funds, and other grant sources. The survey uses bubble-sheet formatting with respondent anonymity maintained through the exclusion of identifying information on the form.
The 46-question survey comprehensively assesses youth health knowledge, attitudes, and behaviors related to substance use and decision-making. Questions address alcohol consumption, tobacco use, marijuana use, prescription drug misuse, and electronic vaping device use within the past 30 days, along with perception of peer substance use behaviors. Additional sections evaluate decision-making processes, risk perception related to various substances, perceived wrongness of substance use, peer influence regarding substance use, self-efficacy in refusing drugs or alcohol across various scenarios, and parental engagement on substance use topics. Demographic questions capture grade level, gender, and race/ethnicity. The survey includes a completion verification question for post-program administration. This standardized assessment instrument enables the Office of Drug Policy to measure program impacts and collect data necessary for performance evaluation across its grant-funded youth substance abuse prevention and intervention initiatives.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP # 624 Assessment and Evaluation Admin Doc.docx | DOCX document |
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Text version
YOUTH SURVEY:
Grades 6-12
Mandatory program use:
Survey Timeframe: Pre Post
Optional program use:
This survey is designed to give us information about your health knowledge, attitudes and behaviors. Please answer all of the questions honestly. Your answers are confidential – no one will ever know how you answered.
Please bubble in the response that best matches your answer. Do not put your name on this form.
Please completely fill in the bubble for your answer: xx Like This: NOT Like This: xx
During the past 30 days, did you ever… Yes No
1. Drink alcoholic beverages (beer, wine, or hard liquor) – more than just a few sips?
2. Have 5 or more drinks of an alcoholic beverage in a row?
3. Use tobacco in any form (including cigarettes, chewing tobacco, snuff, dip, or vape)?
4. Use marijuana in any form (including pot, weed, edibles, or vape)?
5. Misuse prescription drugs?
6. Use electronic vaping devices (including e-cigarettes, vape pens, or JUUL)?
During the past 30 days, do you think your friends ever… Yes No
7. Drank alcoholic beverages (beer, wine, or hard liquor) – more than just a few sips?
8. Had 5 or more drinks of an alcoholic beverage in a row?
9. Used tobacco in any form (including cigarettes, chewing tobacco, snuff, dip, or vape)? ...
10. Used marijuana in any form (including pot, weed, edibles, or vape)?
11. Misused prescription drugs?
12. Used electronic vaping devices (including e-cigarettes, vape pens, or JUUL)?
Mark only one answer for each question. Select the answer that best fits you.
Never
Sometimes but not often Often
All the time
13. How often do you stop to think about your options before you make a decision?
14. How often do you stop to think about how your decisions may affect others’ feelings?
15. How often do you stop and think about all of the things that may happen as a result of your decisions?
16. I make good decisions
How much do you think people risk harming themselves physically and in other ways when they…
No risk
Slight risk
Moderate risk
Great risk
17. Smoke one or more packs of cigarettes per day?
18. Use chewing tobacco, snuff, or dip?
19. Use marijuana once or twice per week?
20. Have one or two alcoholic beverages nearly every day?
21. Have five or more drinks of an alcoholic beverage once or twice a week?
22. Misuse prescription drugs?
23. Use electronic vaping devices (including e-cigarettes, vape pens, or JUUL)? .
Please continue on the other side
How wrong do you think it is for someone your age to... Not at all wrong
A little bit wrong Wrong
Very wrong
24. Drink alcohol?
25. Have five or more alcoholic beverages once or twice per week?
26. Use tobacco?
27. Use marijuana?
28. Misuse prescription drugs?
29. Use electronic vaping devices (including e-cigarettes, vape pens, or
JUUL)?
How wrong do your friends feel it would be for YOU to… Not at all wrong
A little bit wrong Wrong
Very wrong
30. Drink alcohol?
31. Have five or more alcoholic beverages once or twice per week?
32. Use tobacco?
33. Use marijuana?
34. Misuse prescription drugs?
35. Use electronic vaping devices (including e-cigarettes, vape pens, or
JUUL)?
How sure are you that you could say NO to drugs or alcohol if you really wanted to if…
I am not sure at all that I can say no
I am slightly sure I can say no
I am somewhat sure I can say no
I am mostly sure I can say no
I am completely sure I can say no
36. You are at a party where most people are using it?
37. A very close friend suggests that you use it?
38. You are home alone and feeling sad or bored?
39. You are on school property and someone offers it?
40. You are hanging out at a friend’s house whose parents aren’t home?
In the past 6 months… Yes No
41. Have you talked with at least one of your parents/caregivers about the dangers of tobacco, alcohol, or drug use?
42. Have you and either of your parents/caregivers discussed family rules or expectations about using drugs?
Please answer the following question at the end of the program only:
43. Did you also take this survey at the beginning of the program?
44. What grade are you in?
6th
7th
8th
9th
10th
11th
12th
45. What is your gender?
Male
Female
Other
I prefer not to say
46. What is your race/ethnicity? (Mark all that apply)
White
Black or African- American
Hispanic
Asian
Native Hawaiian/ Other Pacific Islander
American Indian/ Alaska Native
Thank you for taking part in this survey!
File details come from the government source that posted it. Updated .