A Drug, Alcohol, and Substance Abuse Survey

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We have a major drug, alcohol, and substance abuse problem in our country.

Without a way to measure the extent of this problem, however, how can we tell if our educational, preventative, intervention-oriented, and our disciplinary efforts by our school systems, law enforcement agencies, social service agencies, and treatment facilities are successful or not?

The Department of Mental Health and Addiction Services in each state needs to construct a "Drug, Alcohol and Substance Abuse" survey form that can be administered to all of the elementary, junior high, school, high school, and college students in the state.

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The Contents of the Survey*

We are trying to determine the extent that students engage in drug, alcohol, and/or substance abuse. Since your identity is not known, please answer these questions as honestly as possible.

What is your age? ____________

What is your grade? ___________

What is your gender? Male ____________ Female _____________

What is your race?

Black/African American __________

White ____________

Hispanic or Latino __________

Asian _____________

Native Hawaiian or Other Pacific Islander ______________

American Indian or Alaska Native ______________

Have you ever consumed alcohol or taken a drug or a substance? Please check all that apply.

Alcohol ___________

Drugs ____________

Substances ________

What is the name(s) of the drug you took? Examples include the following: marijuana, Ecstasy, cocaine, meth, Oxycontin, Percocet, Vicodin, Percodan, LSD, Molly, heroin, PCP, and crack. Please include all of the drugs you have ever taken.

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What is the name(s) of the substance you took? Examples include the following: paint thinner, aerosols, propane, nitrous oxide, dry cleaning fluid, spot remover, glue, nail polish remover, typewriter correction fluid (white out), paint thinner, lighter fluid, gasoline and butane. Please include all of the substances you have ever taken.

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Have you had any alcohol in the past 30 days?   Yes __________ No ___________

Have you ever engaged in binge drinking? (Binge drinking is defined as having 4 or more drinks in one sitting for females and 5 or more drinks in one sitting for males).

Yes __________ No ___________

Have you engaged in binge drinking in the past 30 days?    Yes _________ No ___________

How often do you engage in binge drinking each month?

Once _____________

Twice _____________

Three times _____________

4 or more times _____________

Have you used a drug or substance in the past 30 days?  Yes ___________ No ____________

Have you ever gotten "high" on alcohol, drugs, or substances?   Yes __________ No __________

Place a check mark next to the item you have taken to get a "high". Please check all that apply.

Alcohol _____________

Drugs ______________

Substances __________

What is the name(s) of the drug you took to get high on?  Please include the names of all of the drugs you have ever gotten "high" on. Examples include the following: marijuana, Ecstasy, cocaine, meth, Oxycontin, Percocet, Vicodin, Percodan, LSD, Molly, heroin, PCP, and crack.

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What is the name(s) of the substance you took to get high on? Please include the names of all of the substances you have ever used to get "high on." Examples include the following: paint thinner, aerosols, propane, nitrous oxide, dry cleaning fluid, spot remover, glue, nail polish remover, typewriter correction fluid (white out), paint thinner, lighter fluid, gasoline and butane.

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How old were you when you first starting drinking alcohol? _________________

How old were you when you first starting taking drugs (excluding alcohol)? _______________

What is the name of the first drug you took?? Examples include the following: marijuana, Ecstasy, cocaine, meth, Oxycontin, Percocet, Vicodin, Percodan, LSD, Molly, heroin, PCP, and crack.

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How old were you when you first starting abusing substances? _______________

What is the name of the first substance you took? Examples include the following: paint thinner, aerosols, propane, nitrous oxide, dry cleaning fluid, spot remover, glue, nail polish remover, typewriter correction fluid (white out), paint thinner, lighter fluid, gasoline and butane.

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How often every month do you get "high" on drugs?

Once _____________

Twice _____________

Three times _____________

4 or more times _____________

How often every month do you get "high" on substances?

Once _____________

Twice _____________

Three times _____________

4 or more times _____________

Have you ever had to be taken to the hospital for an alcohol, drug, or substance related problem?  Yes _________ No ___________

Have you ever overdosed from alcohol, drugs, or from substances? Yes _______ No _________

What did you overdose on? Please check all that apply.

Alcohol _____________

Drugs _____________

A Substance _____________

If you overdosed on drugs, what was the name(s) of the drug on which you overdosed? Examples include the following: marijuana, Ecstasy, cocaine, meth, Oxycontin, Percocet, Vicodin, Percodan, LSD, Molly, heroin, PCP, and crack.

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If you overdosed on substances, what was the name(s) of the substance on which you overdosed? Examples include: paint thinner, aerosols, propane, nitrous oxide, dry cleaning fluid, spot remover, glue, nail polish remover, typewriter correction fluid (white out), paint thinner, lighter fluid, gasoline and butane.

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How many times have you overdosed from alcohol, drugs, or from substances?

Once ___________________

Twice ___________________

Three times ___________________

4 or more times __________________

Have you ever driven while under the influence of alcohol, drugs, or substances?    Yes ________ No ________

List the items that you took while you were driving. Please check all that apply.

Alcohol ____________

Drugs _____________

Substances _________

Have you ever experienced a "blackout" from drinking alcohol    Yes ______ No _______

How many times have you experienced a blackout from drinking alcohol?

Once __________________

Twice ___________________

Three times ___________________

4 or more times __________________

Have you every received a ticket for "driving under the influence" (DUI)? Yes _________ No _________

Was your DUI from drinking alcohol?   Yes ____________ No ________________

Was your DUI from taking drugs?  Yes _______________ No _______________

Was your DUI from substance abuse?   Yes _______________ No _______________

In what city and county did your first DUI take place? ______________       _____________

In what city and county did your second DUI take place? ______________       _______________

In what city and county did your third DUI take place? ______________     _______________

Have you ever been the driver in an alcohol-related motor vehicle accident?   Yes ______ No _______

Have you ever been the driver in an a drug-related motor vehicle accident?  Yes ______ No _______

Have you ever been the driver in a substance-related motor vehicle accident?  Yes ______ No _______

Have you ever received professional treatment or rehab for alcohol, drug, or substance abuse? Yes _______ No ________

Are you currently receiving professional treatment or rehab for alcohol abuse or alcoholism? Yes _______ No __________

Are you currently receiving professional treatment or rehab for drug abuse or drug addiction?   Yes _______ No __________

Are you currently receiving professional treatment or rehab for substance abuse?   Yes _______ No __________

What Will This Survey Accomplish

This drug, alcohol and substance abuse survey will accomplish the following.

  • It will standardize the information that is collected.

  • It will save school and college administrators throughout the state money since they will not have to develop their own survey form.

  • It can be used to identify the drugs that are being abused in a community (by race, gender, age, and grade).

  • It can be used to identify how many students drink alcohol (by race, gender, age, and grade).

  • It can be used to determine how many students engage in binge drinking and how often they do this (by race, gender, age, and grade).

  • It can be used to determine the drug, alcohol, and substance abuse that currently exists (by race, gender, age, and grade). This information can be reviewed each year to chart differences and to compare the findings from one year to another.

  • It can be used to determine how effective the educational, preventative, intervention-oriented, and the disciplinary efforts have been by our school systems, law enforcement agencies, social service agencies, and treatment facilities have been.

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The Shortcomings of This Survey

The major drawbacks of this "drug, alcohol, and substance abuse" survey are the following:

  • It doesn't tap into the drug, alcohol, and substance abuse information of high school and college students who dropped out of or who were kicked out of school.

  • It doesn't tap into the drug, alcohol, and substance abuse information of people who are non-students such as the vast majority of adults.

* Note. This survey was developed by the author of this website. As a result, there are no references.

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