SURVEY ON RISKY BEHAVIOR: DRIVING, TOBACCO, ALCOHOL, AND DRUGS

This survey will not be accepted unless the first 10 entries are filled.

This survey is anonymous. NO record can be made of you or your internet address.

The code name should be 6 to 12 characters long. Use only alphabets [a-z] and numbers [0-9]. No blank spaces. This same code name should be used by you if you fill out the survey later in life.

Please answer all questions. Skip questions only if they absolutely do not apply to you.

If you found this survey helpful, please ask your friends to fill it also. Your participation will help us design a more interactive survey that provides you feedback, correct answers, and advise

  1. GIVE YOURSELF A CODE NAME THAT YOU WILL REMEMBER:

  2. TODAY's DATE (dd/mm/yyyy):

  3. YOUR AGE:

  4. YOUR SEX:

    Male  
    Female

  5. YOUR SCHOOL'S NAME:

  6. CLASS YOU ARE IN AT SCHOOL (OR YOUR HIGHEST DEGREE):

  7. NAME OF CITY YOU LIVE IN:

  8. NAME OF COUNTRY YOU LIVE IN:

  9. YOUR PARENTS (OR YOUR) PROFESSION

    PROFESSIONAL (doctor, lawyer, teacher ...)   
    BUSINESSPERSON, SHOPKEEPER  
    WORKER (factory, farm, municipal, house)  
    POLITICIAN  
    PROFESSIONAL SPORTSPERSON  
    NEWSPAPER, TV, REPORTER  
    ARTIST (MUSICIAN, PAINTER, DANCER)  
    OTHER SPECIFY

  10. YOUR FAMILY's ECONOMIC STATUS

    POOR   
    LOWER MIDDLE CLASS  
    MIDDLE CLASS   
    UPPER MIDDLE CLASS  
    RICH   
    VERY RICH   
    OTHER SPECIFY

  11. DO YOU KNOW HOW TO DRIVE A SCOOTER OR MOTORCYCLE OR CAR

    YES  
    NO  
    LEARNING  

  12. DO YOU HAVE EASY ACCESS TO A SCOOTER/MOTORCYCLE/CAR THAT YOU CAN USE?

    YES  
    NO  
    SOMETIMES  

  13. DO YOU LIKE TO DRIVE?

    YES  
    NO  
    SOMETIMES  

  14. DO YOUR PARENTS PUT RESTRICTIONS ON YOUR DRIVING?

    YES  
    NO  
    SOME  

  15. DO YOU DRIVE RASHLY?

    YES  
    NO  
    SOMETIMES  

  16. WHAT ARE YOUR REASONS FOR DRIVING SAFELY?

    AFRAID OF HAVING AN ACCIDENT  
    RESPECT FOR OTHERS  
    RESPECT FOR THE LAW  
    OTHER, SPECIFY 

  17. HOW MANY CLOSE FRIENDS OR RELATIVES DO YOU KNOW WHO HAVE BEEN IN AN ACCIDENT?

    NO ONE  
    ONE  
    2 - 5  
    5-10  SPECIFY 
    MORE THAN 10  

  18. HAVE YOU EVER TRIED SMOKING?

    YES  
    NO  

  19. IF NOT, WHY DID YOU DECIDE NOT TO TRY?

    DO NOT LIKE THE IDEA  
    AFRAID OF PARENTS/OTHERS  
    NEED MONEY FOR OTHER THINGS  
    NO OPPORTUNITY  
    UNDERSTAND RISKS TO YOUR HEALTH  
    OTHER, SPECIFY 

  20. IF YES, WHAT MADE YOU TRY?

    CURIOSITY  
    PEER PRESURE  
    ANGER AND FRUSTRATION  
    TO IMPRESS OTHERS  
    YOU AND YOUR FRIENDS THINK SMOKING IS COOL  
    OTHER, SPECIFY 

  21. DO YOU SMOKE REGULARLY?

    YES  
    NO  

  22. HOW MANY CIGARETTES A DAY DO YOU SMOKE?

  23. SINCE HOW MANY YEARS DO YOU SMOKE?

  24. DO YOUR PARENTS SMOKE REGULARLY?

    YES  
    NO  

  25. DO YOU KNOW THAT CIGARETTE SMOKING IS VERY ADDICTIVE?

    YES  
    NO  

  26. DO YOU KNOW THAT CIGARETTES CAN CAUSE CANCER AND MANY OTHER DISEASES THAT MAKE LATER LIFE VERY DIFFICULT AND UNPLEASENT?

    YES  
    NO  

  27. DO YOU DRINK ALCOHOL -- BEER, WINE, WHISKY?

    NO  
    RARELY (LESS THAN ONCE A WEEK)  
    OCCASIONLY (ONCE A WEEK)  
    OFTEN (FEW TIMES A WEEK)  
    REGULARLY (DAILY)  

  28. IF NO, WHY DID YOU DECIDE NOT TO TRY?

    DO NOT LIKE THE IDEA  
    AFRAID OF PARENTS/OTHERS  
    NEED MONEY FOR OTHER THINGS  
    NO OPPORTUNITY  
    UNDERSTAND RISKS TO YOUR HEALTH  
    OTHER, SPECIFY 

  29. IF YES, DO YOU LIKE THE TASTE AND SENSATION PRODUCED BY ALCOHOL?

    YES  
    NO  
    NOT SURE  

  30. IF YES, WHAT MADE YOU TRY?

    CURIOSITY  
    PEER PRESURE  
    ANGER AND FRUSTRATION  
    TO IMPRESS OTHERS  
    YOU AND YOUR FRIENDS THINK GETTING HIGH IS COOL  
    OTHER, SPECIFY 

  31. DO YOUR PARENTS DRINK?

    NO  
    RARELY (LESS THAN ONCE A WEEK)  
    OCCASIONLY (ONCE A WEEK)  
    OFTEN (FEW TIMES A WEEK)  
    REGULARLY (DAILY)  

  32. DO YOU KNOW THAT ALCOHOL IS ADDICTIVE AND HARMS YOUR LIVER AND BRAIN?

    YES  
    NO  

  33. DO YOU KNOW THAT ALCOHOL USE IS THE LARGEST RISK FACTOR FOR?

    DRIVING ACCIDENTS   
    DOMESTIC VIOLENCE - WIFE BEATING   
    ILLEGAL DRUG USE  
    LIVER DISEASE  
    RISKY SEX  
    IMPOTENCE   

  34. WHICH OF THE FOLLOWING DRUGS HAVE YOU EVER TAKEN/TRIED?

    HASHISH, CHARAS, GANJA, MARIJUANA   
    SPEED, SLEEPING PILLS   
    PSYCEDELIC DRUGS LIKE LSD  
    COCAINE, MORPHINE, HEROIN   
    OTHER, SPECIFY 

  35. HOW MANY TIMES HAVE YOU TRIED DRUGS?

  36. SINCE HOW MANY YEARS HAVE YOU BEEN USING DRUGS?

  37. WHICH DRUGS ARE YOU USING NOW?

    HASHISH, CHARAS, GANJA, MARIJUANA   
    SPEED, SLEEPING PILLS   
    PSYCEDELIC DRUGS LIKE LSD  
    COCAINE, MORPHINE, HEROIN   
    OTHER, SPECIFY 

  38. DO YOU KNOW WHY DRUGS ARE DANGEROUS?

    THEY ARE ADDICTIVE   
    IMPAIR JUDGEMENT LEADING TO RISKY BEHAVIOR AND ACCIDENTS   
    YOU NEVER KNOW WHAT ALL IS IN THEM   
    RUIN YOUR HEALTH   
    DESTROY YOUR WHOLE FAMILY   
    COULD KILL YOU   
    NOT SURE   
    OTHER, SPECIFY 

  39. DO YOU KNOW THAT TAKING DRUGS INTRAVENOUSLY (VIA NEEDLES) POSE MAXIMUM RISK FOR THESE DEADLY DISEASES?

    HIV/AIDS   
    HEPATITIS B   
    HEPATITIS C   
    NOT SURE   

  40. WHAT ARE YOUR FRIENDS ATTITUDES TOWARDS SMOKING, DRINKING, DRUGS?

    NO WAY  
    TOO DANGEROUS  
    NO HARM TRYING  
    OK TO DO IT AT PARTIES  
    OK SOMETIMES  
    THEY ARE VERY EXCITING AND FUN, SO DO IT  
    SMOKING IS FUN  
    DRINK WHENEVER YOU CAN  
    DRUGS ARE COOL  
    OTHER, SPECIFY