FIRST NAME:______LAST NAME: ______
Codebook-Baseline 2017
Strategies for Success
Middle School
Module A - ATOD
Do not write in this box. For office use only.
SFS VERSION ID: ATODMID
version
ID#
Site ID Group Participant ID
site gid pid
Date of administration:
bdate Month Day Year
Language of administration: 1 English
(Circle appropriate number) 2 Spanish
language 3 Other, Specify ______
Location of administration: 1 School
location 2 Home
3 Program/evaluation office
4 Other, Specify ______
Type of administration 1 Individual
type 2 Group
Survey Version: 1 Baseline
2 Posttest
Please PRINT your name clearly at the top and then tear off this Sheet and hand in to the survey administrator.
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Directions: Please read each question and circle your response or put an X in the box next to it.
1) BA01 How old are you?
10 10 years old or younger
11 11 years old
12 12 years old
13 13 years old
14 14 years old
15 15 years old
16 16 years old or older
2) BA02 Are you female or male?
0 Male 1 Female
3) BA03In what grade are you?
5 5th grade 8 8th grade
6 6th grade 9 9th grade
7 7th grade 0 Not in school
4) How do you describe yourself? (Check all that apply.) For each item enter 1 if selected. If not selected, leave it blank.
BA04_1 American Indian or Alaskan Native BA04NAMTribe(s):______
BA04_2Asian
BA04_3Black or African American
BA04_4Hispanic or Latino (such as Mexican, Chicano, Mexican-American, Hispano, Spanish, other Hispanic or Latino)
BA04_5Native Hawaiian or Other Pacific Islander
BA04_6White
5) BA05Do you often speak a language other than English at home?
0 No 1 Yes
6) BA06What is the highest level of schooling your mother completed?
1 Less than high school
2 High school graduate or GED
3 Some college or technical school
4 College graduate, graduate or professional school graduate
999 Not sure
7) BA07What is the highest level of schooling your father completed?
1 Less than high school
2 High school graduate or GED
3 Some college or technical school
4 College graduate, graduate or professional school graduate
999 Not sure
8) BA08 How wrong do your parents feel it would be for you to drink alcohol (beer, wine, or hard liquor) regularly?
0 Very wrong 2 A little bit wrong
1 Wrong 3 Not wrong at all
9) BA09How wrong do you think it is for someone your age to drink alcohol (beer, wine, or hard liquor) regularly?
0 Very wrong 2 A little bit wrong
1 Wrong 3 Not wrong at all
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How much do people risk harming themselves (physically and in other ways) when they…
10) …smoke one or more packs of cigarettes per day? BA10 / No Risk 0 / Slight Risk 1 / Moderate Risk 2 / Great Risk 311) …use electronic vapor products (i.e., e-cig, vapes) on a daily basis? BA11 / No Risk 0 / Slight Risk 1 / Moderate Risk 2 / Great Risk 3
12) …smoke marijuana once a month or more? BA12 / No Risk 0 / Slight Risk 1 / Moderate Risk 2 / Great Risk 3
13) …smoke marijuana once or twice a week? BA13 / No Risk 0 / Slight Risk 1 / Moderate Risk 2 / Great Risk 3
14) …have one or two drinks of an alcoholic beverage (beer, wine, or liquor) nearly every day? BA14 / No Risk 0 / Slight Risk 1 / Moderate Risk 2 / Great Risk 3
15) …have five or more drinks of an alcoholic beverage once or twice a week? BA15 / No Risk 0 / Slight Risk 1 / Moderate Risk 2 / Great Risk 3
16) …use prescription painkillers for a non-medical reason? BA16 / No Risk 0 / Slight Risk 1 / Moderate Risk 2 / Great Risk 3
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17) During the past 30 days, on how many days did you smoke cigarettes? BA17
0 0 days 4 10 to 19 days
1 1 or 2 days 5 20 to 29 days
2 3 to 5 days 6 All 30 days
3 6 to 9 days
18) During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garret, Beechnut, Skoal, Skoal Bandits, or Copenhagen? BA18
0 0 days 4 10 to 19 days
1 1 or 2 days 5 20 to 29 days
2 3 to 5 days 6 All 30 days
3 6 to 9 days
19) If you used any tobacco product in the last 30 days, where did you get them? This includes cigarettes, checking tobacco, snuff, electronic vapor product, cigars cigarillos, (Check all that apply). For each item enter 1 if selected. If not selected, leave it blank.
I have not used tobacco products in the past 30 days. BA19_1
An adult family member gave it or bought it for me. BA19_2
Someone not related to me who is 18 or older gave it or bought it for me. BA19_3
My parent or guardian gave it or bought it for me. BA19_4
I took it from my home or someone else’s home. BA19_5
I bought it at a store. BA19_6
Someone under age 18 bought or gave it to me. BA19_7
I got it some other way. BA19_8
[Please describe]: BA19oth______
20) Do you think you will try smoking a cigarette soon?
BA20
66 I have already tried smoking cigarettes
0 No
1 Yes
21) Do you think you will smoke a cigarette at any time during the next year? BA21
0 Definitely yes
1 Probably yes
2 Probably not
3 Definitely not
22) If one of your best friends offered you a cigarette, would you smoke it? BA22
0 Definitely yes
1 Probably yes
2 Probably not
3 Definitely not
23) Have you ever had a drink of alcohol, other than a few sips? BA23
0 No 1 Yes
24) During the past 30 days, on how many days did you have at least one drink of alcohol? BA24
0 0 days 4 10 to 19 days
1 1 or 2 days 5 20 to 29 days
2 3 to 5 days 6 All 30 days
3 6 to 9 days
25) During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours? BA25
0 0 days 4 6 to 9 days
1 1 day 5 10 to 19 days
2 2 days 6 20 or more days
3 3 to 5 days
26) During the past 30 days, how did you get the alcohol you drank? (Check all that apply.) For each item enter 1 if selected. If not selected, leave it blank.
I have not drunk alcohol in the past 30 days. BA26_1
I got it at a party. BA26_2
My parent or guardian gave it or bought it for me. BA26_3
Another adult family member who is 21 or older gave it or bought it for me. BA26_4
Someone not related to me who is 21 or older gave it or bought it for me. BA26_5
Someone under age 21 bought or gave it to me. BA26_6
I took it from my home or someone else’s home. BA26_7
I bought it at a store, restaurant, bar or public place. BA26_8
I got it some other way. BA26_9
[Please describe]: BA26oth______
27) Have you ever used marijuana (pot)? BA27
0 No 1 Yes
28) During the past 30 days, how many times did you use marijuana? BA28
0 0 times 3 10 to 19 times
1 1 or 2 times 4 20 to 39 times
2 3 to 9 times 5 40 or more times
29) During the past 30 days, how many times have you taken a prescription stimulant such as Ritalin or Adderall not prescribed to you? BA29
0 0 times 3 10 to 19 times
1 1 or 2 times 4 20 to 39 times
2 3 to 9 times 5 40 or more times
30) During the past 30 days, how many times did you use a pain killer to get high, like Vicodin, OxyContin (also called Oxy or OC), or Percocet (also called Percs)? BA30
0 0 times 3 10 to 19 times
1 1 or 2 times 4 20 to 39 times
2 3 to 9 times 5 40 or more times
31) If you used painkillers in the last 30 days for any reason, where did you get them? (Check all that apply). For each item enter 1 if selected. If not selected, leave it blank.
I didn’t use prescription pain killers in the last 30 days BA31_1
A doctor or dentist prescribed or gave them to me BA31_2
A family member shared them with me BA31_3
A friend shared them with me BA31_4
They were bought from somebody (e.g., friend, dealer, family member) BA31_5
They were taken from someone (including friends or relatives) without asking BA31_6
Other place (e.g., Mexico, internet) BA31_7
please describe BA31oth:______
32) Have you ever sniffed glue, or breathed the contents of spray cans, or inhaled any paints or sprays to get high? BA32
0 No 1 Yes
33) If you are drinking alcohol at school, how likely are you to get caught by teachers or staff? BA33
1 Very unlikely 3 Likely
2 Unlikely 4 Very likely
34) If you get caught drinking at school, how likely are you to get into trouble with school? BA34
1 Very unlikely 3 Likely
2 Unlikely 4 Very likely
35) If you are drinking alcohol anywhere in your community, how likely are you to get caught by the police? BA35
1 Very unlikely 3 Likely
2 Unlikely 4 Very likely
36) If you are drinking alcohol anywhere in your community, how likely are you to get arrested or cited by the police? BA36
1 Very unlikely 3 Likely
2 Unlikely 4 Very likely
Q37 & Q38 are media campaigns questions. We use a new set of letters to represent them:
Q37=BM1 (baseline media1)
Q38=BM2 (baseline media2)
37) The following is a list of different drug prevention media campaigns. Please check the box next to all those you recognize or have heard of: For each item enter 1 if selected. If not selected, leave it blank.
Be the Solution BM1_1
Suck It Up! BM1_2
Good Drugs Gone Bad BM1_3
Parents Who Host Lose the Most BM1_4
A Dose of Reality BM1_5
Up and Away and Out of Sight BM1_6
Wake Up Now BM1_7
I’ve never heard of any of these. BM1_8
38) What do you think is the main prevention message of the campaign “A Dose of Reality”? Check only one option. For each item enter 1 if selected. If not selected, leave it blank.
Stay in school if you want to be successful. BM2_1
Prescription drugs can be dangerous if not used as intended. BM2_2
Reality is harsh, but medication can help. BM2_3
Daily exercise is good for your health. BM2_4
Take your medication as directed by your doctor. BM2_5
Vaccinate your kids. BM2_6
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