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Be Aware! Youth Survey on Alcohol Usage
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Be Aware! Youth Survey on Alcohol Usage
Be Aware! Youth Survey on Alcohol Usage
Step
1
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8
12%
About You
Please tell us some basic information about you.
Your Gender:
*
Please Select
Male
Female
Your Grade:
*
Please Select
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Non-High Schoolers / 21+
Your Age:
*
Your Racial Identity/Ethnicity:
*
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White
Prefer not to respond
Multi-racial
Other
Your Sexual Orientation:
*
Please Select
Heterosexual
Gay
Lesbian
Bisexual
Questioning
Prefer not to respond
Your County:
*
Please Select
Butler
Fillmore
Gage
Jefferson
Johnson
Lancaster
Nemaha
Otoe
Pawnee
Polk
Richardson
Saline
Saunders
Seward
Thayer
York
Zip Code:
*
About Your Alcohol Use
In order to properly assess your alcohol use and share how it may be negatively affecting you, we need to ask you some additional personal questions.
Have you drunk alcohol in the last year?
*
Yes
No
Have you drunk alcohol in the last month?
*
Yes
No
Cheers! You deserve a round of applause! Congratulations for making the smart and healthy choice to not drink alcohol underage. We know that adolescence can be a difficult time filled with peer pressure and opportunities for risky behavior. Please understand that by making the choice to resist underage drinking, you’re serving as a leader and a source of inspiration to many of your fellow schoolmates – whether they’ll admit it or not. And since you're already making smart choices, you get to skip a few pages in the survey, too!
About Your Alcohol Use
Please think of one (1) occasion when you drank the most alcohol. Fill in the number of standard drinks you consumed and the number of hours you were drinking. If you didn't have a drink, enter zero (0).
Beer
Wine
Liquor
Hours
Your Weight
Did this occasion - when you drank the most - occur in the last month?
Yes
No
About You
Have the following happened to you while you were drinking - or because of your drinking - in the past six (6) months?
Went to work or school high?
Yes
No
Went to work or school drunk?
Yes
No
Went to work or school high and drunk at the same time?
Yes
No
Not able to do your homework or study for a test?
Yes
No
Missed a day (or part of a day) of school or work?
Yes
No
Got into fights, acted badly, or did mean things?
Yes
No
Had legal trouble?
Yes
No
Passed out or fainted suddenly?
Yes
No
Experienced nausea or vomiting?
Yes
No
Suddenly found yourself in a place you could not remember getting to (i.e., blackout)?
Yes
No
About You
Have the following things happened to you while you were drinking - or because of your drinking - in the past six (6) months?
Experienced embarrassment or shame because of something you did?
Yes
No
Had sex with someone you would not have, had you been sober, or did not use protection when you had sex?
Yes
No
Had sex with someone who was extremely intoxicated?
Yes
No
Felt that you had a problem with alcohol?
Yes
No
Was told by a friend or loved one to stop or cut down on drinking?
Yes
No
Tried to cut down or quit drinking?
Yes
No
Contemplated or attempted self-harm (i.e., cutting)?
Yes
No
Contemplated or attempted to complete suicide?
Yes
No
Received treatment or been hospitalized for Acute Alcohol Toxicity (also known as Alcohol Poisoning)?
Yes
No
About You
In the last month, how many days did you drive a vehicle after drinking alcohol?
In the last month, how many days were you a passenger in a vehicle driven by someone who had been drinking alcohol?
About Your Family
In your family, how many of your blood relatives are currently (or have been in the past) problem drinkers or alcoholics?
Number of parents:
Number of brothers/sisters:
Number of grandparents:
Number of first cousins:
About Your Perceptions
Do you approve of students drinking before the age of 21?
Yes
No
Do you approve of students drinking so much that one gets sick?
Yes
No
Do you approve of students driving after drinking alcohol?
Yes
No
For the following questions, please give your best estimate:
What percentage of students your same gender and age group do you think approve of drinking before the age of 21?
What percentage of students your same gender and age group do you think approve of drinking so much that one gets sick?
What percentage of students your same gender and age group do you think approve of drinking and driving?
About Your Goals
Please mark any of the personal goals you would like to achieve now, and in the next 5-10 years:
Participate in team sports or extracurricular activities
Yes
No
Graduate with a high school diploma or GED
Yes
No
Attend a two-year or four-year college or university
Yes
No
Save enough money to purchase a vehicle, go traveling or help pay for college
Yes
No
