Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.This is an anonymous assessment. Answer every question to the best of your ability. Thank you for your participation! Date *School *--- Select Choice ---Henrietta JHBarwise JHHenrietta HSBurkburnett HSIowa Park HSIowa Park JHBurkburnett JHPetroliaNoconaNewcastleJJAEPCity ViewGrandfieldAge *Gender *FemaleMaleGrade *Name of Prevention SpecialistChoice 1Billy BobCool ChelseaHave you taken this questionnaire within this school year? *YesNoRace/ Ethnicity *American Indian/Alaskan NativeAsianBlack/African AmericanHispanic/LatinoMiddle Eastern/North AfricanMultiracial/MultiethnicNative Hawaiian/Pacific IslanderWhiteOtherOther Race/ Ethnicity *Please type your race/ ethnicity.Select the option that best describes your living situation *I live in the same home with both parentsI live with one parentI live with a relative other than my parentsI live in a temporary home or homelessHow safe do you feel at each of these locations? * Very safeSomewhat safeNot safe In your homeVery safeIn your home Very safeSomewhat safeIn your home Somewhat safeNot safeIn your home Not safeIn your neighborhoodVery safeIn your neighborhood Very safeSomewhat safeIn your neighborhood Somewhat safeNot safeIn your neighborhood Not safeAt schoolVery safeAt school Very safeSomewhat safeAt school Somewhat safeNot safeAt school Not safe Social Media Use & BullyingThe next set of questions ask about bullying and social media use, including platforms such as Tik Tok, Snapchat, Facebook, Messenger Apps, Instagram, Roblox, Minecraft, YouTube, Pinterest, Twitch, Discord, and other online gaming networks.IF you have one, what grade were you in when you got your first account? *Before KindergartenK-23-56-89-12How many hours a day do you typically engage in social media? *Less than 1 hour1-2 hours3-4 hours5-6 hours7 or more hoursHow often do you feel the urge to use social media? *NeverRarelySometimesOftenAlwaysHow often do you feel anxious or irritable when you can’t access social media? *NeverRarelySometimesOftenAlwaysHow often do you neglect other responsibilities because of social media use? (i.e. during class, homework, chores, family time etc.) *NeverRarelySometimesOftenAlwaysDo you wish you spent less time on social media? *NeverRarelySometimesOftenAlwaysIn general, does social media make you feel: More connected to content creators and/or influencers *YesNoWorse about your own self-image because of what you see from other friends on social media *YesNoBetter connected to your friends’ feelings/lives *YesNoPressure to post content that will be popular and get lots of likes or comments *YesNoDo you feel rejected, disappointed, or unseen when your posts do not get likes? *YesNoPressure to follow and imitate content creators and/or influencers *YesNoBullyingBullying is when one or more students threaten, spread rumors about, hit, shove, or otherwise hurt another student over and over again. In the last 30 days, how often have you been bullied? * I have not been bulliedOnce2-3 timesAbout once a weekSeveral times a week Extra-CurricularsI have not been bulliedExtra-Curriculars I have not been bulliedOnceExtra-Curriculars Once2-3 timesExtra-Curriculars 2-3 timesAbout once a weekExtra-Curriculars About once a weekSeveral times a weekExtra-Curriculars Several times a weekSchoolI have not been bulliedSchool I have not been bulliedOnceSchool Once2-3 timesSchool 2-3 timesAbout once a weekSchool About once a weekSeveral times a weekSchool Several times a weekOnlineI have not been bulliedOnline I have not been bulliedOnceOnline Once2-3 timesOnline 2-3 timesAbout once a weekOnline About once a weekSeveral times a weekOnline Several times a weekWorkI have not been bulliedWork I have not been bulliedOnceWork Once2-3 timesWork 2-3 timesAbout once a weekWork About once a weekSeveral times a weekWork Several times a weekHomeI have not been bulliedHome I have not been bulliedOnceHome Once2-3 timesHome 2-3 timesAbout once a weekHome About once a weekSeveral times a weekHome Several times a week Please select one answer for each question.I am involved in extracurricular activities. *YesNo(School or community athletics, choir, band, stuco, etc.) I have at least one friend I can trust. *YesNoDo you think bullying is a problem in your school? *YesNoDo you believe cyber-bullying is a problem in your school? *YesNoSubstance UseThe next set of questions ask about substances such as drugs and alcohol; including thoughts about your own use and your friends’ use. Have you ever used any of the following substances? *I have never used one or more of the substances belowI have used one or more of the substances belowAlcohol, Marijuana, Nicotine, Prescription Drugs, Over the Counter Drugs or Illicit (Street) DrugsPlease check any that you have used *AlcoholMarijuanaNicotinePrescription (Rx)Over the Counter (OTC)Illicit Drugs (Street Drugs)Alcohol *BeerWineLiquorAlcopopsMaltsHard seltzersHow old were you the first time you used alcohol? *Before 111112131415161718IDKHave not usedHow often do you use alcohol?Only once, never againA few timesMonthlyWeeklyDailyMarijuana *WeedCBDDelta-8EdiblesDabK-2SpiceOther Cannabis or THC productsName of other Cannabis or THC products *How old were you the first time you used marijuana? *Before 111112131415161718IDKHave not usedHow often do you use marijuana?Only once, never againA few timesMonthlyWeeklyDaily am social describes Nicotine *VapesDip/ Snuff/ ChewCigarsCigarettesAlternativesName of nicotine alternatives *How old were you the first time you used nicotine? *Before 111112131415161718IDKHave not usedHow often do you use nicotine ?Only once, never againA few timesMonthlyWeeklyDailyPrescription Drugs *I only take medicine that is prescribed to meI have misused prescription drugsMisuse means taking someone else's prescription, using more than my prescribed dose or more often than recommended .Prescription Drugs Misuse *I have misused drugs prescribed to meI have misused drugs that are not prescribed to meMisuse means taking more than the prescribed dose or more often than recommended .Name of prescription drugs misusedHow old were you the first time you misused prescription drugs? *Before 111112131415161718IDKHave not usedMisuse means taking more than the prescribed dose or more often than recommendedHow often do you misuse prescription drugs ?Only once, never againA few timesMonthlyWeeklyDailyOver the Counter *I only take "over the counter" drugs as recommendedI have misused over the counter drugsMisuse means taking more than the recommended dose or more often than recommended .Over the Counter Misuse *I have misused "over the counter" drugsI have misused pills that are unknownMisuse means taking more than the recommended dose or more often than recommended .Name of "over the counter" drugs misused How old were you the first time you misused "over the counter" drugs? *Before 111112131415161718IDKHave not usedMisuse means taking more than the prescribed dose or more often than recommendedHow often do you misuse "over the counter" drugs ?Only once, never againA few timesMonthlyWeeklyDailyIllicit Drugs (Street Drugs) *CocaineMethamphetamineHeroinFentanylEcstasyMollyOtherName of other Illicit Drugs (Street Drugs)How old were you the first time you used any of these illicit drugs? *Before 111112131415161718IDKHave not usedHow often do you use any of these illicit drugs ?Only once, never againA few timesMonthlyWeeklyDailyThinking about your close friendsIF they use, how often do they use ? Have never usedOnly once, never againA few timesMonthlyWeeklyDaily AlcoholHave never usedAlcohol Have never usedOnly once, never againAlcohol Only once, never againA few timesAlcohol A few timesMonthlyAlcohol MonthlyWeeklyAlcohol WeeklyDailyAlcohol DailyMarijuanaHave never usedMarijuana Have never usedOnly once, never againMarijuana Only once, never againA few timesMarijuana A few timesMonthlyMarijuana MonthlyWeeklyMarijuana WeeklyDailyMarijuana DailyNicotineHave never usedNicotine Have never usedOnly once, never againNicotine Only once, never againA few timesNicotine A few timesMonthlyNicotine MonthlyWeeklyNicotine WeeklyDailyNicotine DailyPrescription DrugsHave never usedPrescription Drugs Have never usedOnly once, never againPrescription Drugs Only once, never againA few timesPrescription Drugs A few timesMonthlyPrescription Drugs MonthlyWeeklyPrescription Drugs WeeklyDailyPrescription Drugs DailyOver the Counter DrugsHave never usedOver the Counter Drugs Have never usedOnly once, never againOver the Counter Drugs Only once, never againA few timesOver the Counter Drugs A few timesMonthlyOver the Counter Drugs MonthlyWeeklyOver the Counter Drugs WeeklyDailyOver the Counter Drugs DailyIllicit (Street) DrugsHave never usedIllicit (Street) Drugs Have never usedOnly once, never againIllicit (Street) Drugs Only once, never againA few timesIllicit (Street) Drugs A few timesMonthlyIllicit (Street) Drugs MonthlyWeeklyIllicit (Street) Drugs WeeklyDailyIllicit (Street) Drugs DailyOther drugsHave never usedOther drugs Have never usedOnly once, never againOther drugs Only once, never againA few timesOther drugs A few timesMonthlyOther drugs MonthlyWeeklyOther drugs WeeklyDailyOther drugs Daily Illicit or street drugs include cocaine, methamphetamine, fentanyl, heroin, ecstasy, molly, etc.Name of any other drug your close friends useIF you wanted to, where would you get the substance? HomeFriendsOnlineSchoolStoreOther AlcoholHomeAlcohol HomeFriendsAlcohol FriendsOnlineAlcohol OnlineSchoolAlcohol SchoolStoreAlcohol StoreOtherAlcohol OtherMarijuanaHomeMarijuana HomeFriendsMarijuana FriendsOnlineMarijuana OnlineSchoolMarijuana SchoolStoreMarijuana StoreOtherMarijuana OtherNicotineHomeNicotine HomeFriendsNicotine FriendsOnlineNicotine OnlineSchoolNicotine SchoolStoreNicotine StoreOtherNicotine OtherPrescription DrugsHomePrescription Drugs HomeFriendsPrescription Drugs FriendsOnlinePrescription Drugs OnlineSchoolPrescription Drugs SchoolStorePrescription Drugs StoreOtherPrescription Drugs OtherOver the CounterHomeOver the Counter HomeFriendsOver the Counter FriendsOnlineOver the Counter OnlineSchoolOver the Counter SchoolStoreOver the Counter StoreOtherOver the Counter OtherIllicit (Street) DrugsHomeIllicit (Street) Drugs HomeFriendsIllicit (Street) Drugs FriendsOnlineIllicit (Street) Drugs OnlineSchoolIllicit (Street) Drugs SchoolStoreIllicit (Street) Drugs StoreOtherIllicit (Street) Drugs OtherOtherHomeOther HomeFriendsOther FriendsOnlineOther OnlineSchoolOther SchoolStoreOther StoreOtherOther Other (Check all that apply)Name of place to get other drugsHow harmful do you think the following substances are to your health? * Very HarmfulA little harmfulNot harmfulI'm not sure AlcoholVery HarmfulAlcohol Very HarmfulA little harmfulAlcohol A little harmfulNot harmfulAlcohol Not harmfulI'm not sureAlcohol I'm not sureMarijuanaVery HarmfulMarijuana Very HarmfulA little harmfulMarijuana A little harmfulNot harmfulMarijuana Not harmfulI'm not sureMarijuana I'm not sureNicotineVery HarmfulNicotine Very HarmfulA little harmfulNicotine A little harmfulNot harmfulNicotine Not harmfulI'm not sureNicotine I'm not surePrescription drug misuseVery HarmfulPrescription drug misuse Very HarmfulA little harmfulPrescription drug misuse A little harmfulNot harmfulPrescription drug misuse Not harmfulI'm not surePrescription drug misuse I'm not sureOver the counter drug misuseVery HarmfulOver the counter drug misuse Very HarmfulA little harmfulOver the counter drug misuse A little harmfulNot harmfulOver the counter drug misuse Not harmfulI'm not sureOver the counter drug misuse I'm not sureIllicit (Street) DrugsVery HarmfulIllicit (Street) Drugs Very HarmfulA little harmfulIllicit (Street) Drugs A little harmfulNot harmfulIllicit (Street) Drugs Not harmfulI'm not sureIllicit (Street) Drugs I'm not sure During the past year:Have you attended school after drinking alcohol or getting high?YesNoI don't useHave you driven a car after drinking alcohol or getting high?YesNoI don't useHave you been a passenger while the driver was under the influence of drugs or alcohol? YesNoThe driver was *an adulta peerWho has shared information with you about drugs and alcohol before this program? *Parent/guardianSiblingOther relativeFriendsMentorTeacherCounselorCoachChurch leaderPrevention SpecialistOther(Please check all that apply) If you needed help with your substance use, who would you reach out to? *Parent/guardianSiblingOther relativeFriendsMentorTeacherCounselorCoachChurch leaderPrevention SpecialistOther(Please check all that apply) Have you tried to get help from someone for your substance use? *YesNoI don't useIf you need help to quit using substances, what might keep you from seeking it? Fear of punishmentFear of judgementLack of motivation/desireI don’t know where to goI don’t have a problemOther(Please check all that apply)What else might keep you from seeking help? *How would your parents feel about you using substances?My parents have asked me not to use substances, and I don’tMy parents know that I don’t use substancesMy parents know I use substances but don’t approveMy parents don’t know I use substancesMy parents know and are okay with my use(Please check all that apply)Skill development and how you have felt.The final two questions ask you to rate your skill development, and how you have generally felt over the past 3 months.In the past 3 months, how often have you experienced the following? NeverLess than 3 days a monthOnce a week or lessMultiple days per weekMost days A sense of overwhelmNeverA sense of overwhelm NeverLess than 3 days a monthA sense of overwhelm Less than 3 days a monthOnce a week or lessA sense of overwhelm Once a week or lessMultiple days per weekA sense of overwhelm Multiple days per weekMost daysA sense of overwhelm Most daysBeen stressedNeverBeen stressed NeverLess than 3 days a monthBeen stressed Less than 3 days a monthOnce a week or lessBeen stressed Once a week or lessMultiple days per weekBeen stressed Multiple days per weekMost daysBeen stressed Most daysExperienced anxietyNeverExperienced anxiety NeverLess than 3 days a monthExperienced anxiety Less than 3 days a monthOnce a week or lessExperienced anxiety Once a week or lessMultiple days per weekExperienced anxiety Multiple days per weekMost daysExperienced anxiety Most daysBeen depressedNeverBeen depressed NeverLess than 3 days a monthBeen depressed Less than 3 days a monthOnce a week or lessBeen depressed Once a week or lessMultiple days per weekBeen depressed Multiple days per weekMost daysBeen depressed Most daysHad difficulty making friendsNeverHad difficulty making friends NeverLess than 3 days a monthHad difficulty making friends Less than 3 days a monthOnce a week or lessHad difficulty making friends Once a week or lessMultiple days per weekHad difficulty making friends Multiple days per weekMost daysHad difficulty making friends Most daysIntense angerNeverIntense anger NeverLess than 3 days a monthIntense anger Less than 3 days a monthOnce a week or lessIntense anger Once a week or lessMultiple days per weekIntense anger Multiple days per weekMost daysIntense anger Most daysUnresolved conflictsNeverUnresolved conflicts NeverLess than 3 days a monthUnresolved conflicts Less than 3 days a monthOnce a week or lessUnresolved conflicts Once a week or lessMultiple days per weekUnresolved conflicts Multiple days per weekMost daysUnresolved conflicts Most days How confident do you feel in the following areas? * Very confidentSomewhat confidentNot confident Resolving conflictsVery confidentResolving conflicts Very confidentSomewhat confidentResolving conflicts Somewhat confidentNot confidentResolving conflicts Not confidentMaking or maintaining friendsVery confidentMaking or maintaining friends Very confidentSomewhat confidentMaking or maintaining friends Somewhat confidentNot confidentMaking or maintaining friends Not confidentExpressing your feelingsVery confidentExpressing your feelings Very confidentSomewhat confidentExpressing your feelings Somewhat confidentNot confidentExpressing your feelings Not confidentManaging peer pressureVery confidentManaging peer pressure Very confidentSomewhat confidentManaging peer pressure Somewhat confidentNot confidentManaging peer pressure Not confidentDealing with bullying or teasingVery confidentDealing with bullying or teasing Very confidentSomewhat confidentDealing with bullying or teasing Somewhat confidentNot confidentDealing with bullying or teasing Not confident Thank you for completing this survey! Your responses are greatly appreciated and will help us better support students. If you would like to talk to a trusted adult or school counselor regarding anything that came up for you while taking this survey, please ask your Prevention Specialist to connect you with someone you can speak to at your school. You may also call or text 988 (Suicide and Crisis hotline) for additional support and resources. Submit
