| 1. |
What
grade are you now enrolled in at Mountain
Empire High School?
_____ |
| 2. |
What
is your sex? ___
Male ___ Female |
| 3. |
What
is your birthday?
___/____/___ |
| 4. |
Which
of the following best describes your ethnic
or racial background? |
|
- White,
(non-Hispanic)
- Black
(non-Hispanic)
- Hispanic
or Latino
- Asian
or Pacific Islander
- Native
American
- Other
|
| 5. |
How
long have you lived in the Mountain Empire
area? |
|
- Less
than a year
- 1
or 2 years
- 3
to 5 years
- 6
to 10 years
- More
than 10 years
|
| 6. |
What
is your zipcode? _____ |
| 7. |
About
how much money do you have to spend as you
choose each week?
_____ in dollars |
| 8. |
In
the past 12 months, how many times have you
visited... |
|
- Tecate,
Mexico _______ # visits
- Tijuana,
Mexico _______ # visits
- Mexico,
other _______ # visits
|
| 9. |
In
the past 12 months, how many times have you
visited the bars
of... |
|
- Tecate,
Mexico _______ # times
- Tijuana,
Mexico _______ # times
- Mexico,
other _______ # times
|
| 10. |
In the past 12 months, how many times have you made alcohol purchases in
the liquor stores of: |
|
- Tecate,
Mexico _______ # times
- Tijuana,
Mexico _______ # times
- Mexico,
other _______ # times
|
| 11. |
How
old were you when you had your first drink
of alcohol other than a few sips?
(Choose
ONLY ONE response) |
|
- I
have never had a drink of alcohol other
than a few sips
- 8
years old or younger
- 9
or 10 years old
- 11
or 12 years old
- 13
or 14 years old
- 15
or 16 years old
- 17
years old or older
|
| 12. |
During
your life, on how many days have you had at
least one drink of alcohol?
(Choose
ONLY ONE response) |
|
- 0
days
- 1
or 2 days
- 3
to 9 days
- 10
to 19 days
- 20
to 39 days
- 40
to 99 days
- 100
or more days
|
| 13. |
During
the past 30 days, on how many days
did
you have at
least
one drink of alcohol?
(Choose
ONLY
ONE response) |
|
- 0
days
- 1
or 2 days
- 3
to 5 days
- 6
to 9 days
- 10
to 19 days
- 20
to 29 days
- All
30 days
|
| 14. |
During
the past 30 days, on how many days
did
you have 5 drinks of alcohol in a row, that
is,
within a couple of hours? (Choose
ONLY
ONE response) |
|
- 0
days
- 1
day
- 2
days
- 3
to 5 days
- 6
to 9 days
- 10
to 19 days
- 20
or more days
|
| 15. |
Thinking
now of just about the past two weeks, on how
many days did you
have
5 or more drinks of alcohol in a row, that is,
within a couple of hours?
(Choose
ONLY
ONE response) |
|
- 0
days
- 1
day
- 2
days
- 3
days
- 4
days
- 5
days
- 6
or more days
|
| 16. |
From
which of the following sources have you
obtained alcoholic beverages in the past six
months? (Fill in ALL answers that
apply) |
|
- From
a parents home
- From
a friends home
- At
a party (parents present)
- At
a party (parents not present)
- From
a local store
- From
a Mexican store
- From
a local bar
- From
a Mexican bar
- Have
not obtained alcohol in the last six
months
|
| 17. |
Within
the last six months, about how many times did
you obtain alcoholic beverages at each of the
following kinds of stores? (Choose ONLY ONE
response for each store) |
|
|
NUMBER
OF TIMES IN THE PAST SIX MONTHS
|
STORES
|
None
|
Once
|
2-3
times
|
4-6
times
|
6-10
times
|
10+
times
|
Convenience
Store
|
O
|
O
|
O
|
O
|
O
|
O
|
|
Grocery
Store
|
O
|
O
|
O
|
O
|
O
|
O
|
|
Gas
Station
|
O
|
O
|
O
|
O
|
O
|
O
|
|
Liquor
Store
|
O
|
O
|
O
|
O
|
O
|
O
|
|
Bar
in the U.S.
|
O
|
O
|
O
|
O
|
O
|
O
|
|
Bar
in Mexico
|
O
|
O
|
O
|
O
|
O
|
O
|
|
Restaurant
|
O
|
O
|
O
|
O
|
O
|
O
|
|
Store
in Mexico
|
O
|
O
|
O
|
O
|
O
|
O
|
|
| 18. |
Again,
thinking back over the last six months, what
methods did you use to obtain alcoholic
beverages from a store? (Fill in ALL methods
that you have used.) |
|
- Buy
for myself (without a fake ID)
- Buy
for myself (with a fake ID)
- Get
friends to buy it for me
- Get
a stranger to buy it for me
- Parents
buy it for me
- Older
brother/sister buys it for me
- Take
the beverages without paying for them
- Buy
from a store with a young looking clerk
- Buy
from a store I know will sell alcohol to
me
- Buy
for myself in Mexico
- Get
someone to buy it for me in Mexico
|
| 19. |
Which of the following have you experienced in
the past 30 days? (Fill in All statements that
apply
to you) |
|
- I've
ridden in a car with a driver who had been
drinking
- I've
driven a car or motorcycle after drinking
- I've
been cited by police for an alcohol-related
driving violation
- I
know someone who has been cited by police
for an alcohol-driving violation
- I've
thrown up or been ill after drinking
- I've
had enough to drink to feel high, tipsy,
faded or drunk
- I've
been worried about a friends drinking
- I've
had an alcoholic beverage during the
school day
- I've
had a discussion with my parents about
drinking
- I've
thought I ought to cut down or stop my own
drinking
- I've
had an alcoholic drink at a social
occasion when I really didn't want one
- I
did something while drinking that I later
regretted
- I've
had trouble with a friendship because of
someone's drinking
|
| 20. |
How
frequently do you use drugs? (Choose ONLY
ONE response for each drug) |
|
|
|
FREQUENCY
OF USE
|
|
DRUG:
|
Daily
|
Weekly
|
Monthly
|
Yearly
|
Never
|
Marijuana
|
O
|
O
|
| |
