CLINTON

Drug and Alcohol Survey
*Please Check Appropriate Answer to The Following Questions
1) Gender:
Male
Female
2) Age:
Up to 21
22- 25
26-35
36 and Older
3) Classification:
Freshman (0-29 credit hours)
Sophomore (30-59 credit hours)
Junior (60-99 credit hours)
Senior (100 or more credit hours)
4) Grade Point Average (GPA):
A (4.0 or better)
B (3.0-3.9)
C (2.0-2.9)
D (1.0-1.9)
F(Below 1.0)
5) How often do you drink Alcoholic beverages?
Several Times A Week
Once A Week
Twice A Month
Once A Month
Never
6) How often do you use illegal Drugs?
(such as marijuana, ecstasy, meth, angel dust, cocaine, crack, etc)
Several Times A Week
Once A Week
Twice A Month
Once A Month
Never
7) How long have you been drinking alcohol and/or using illegal drugs?
Less than a year
2-3 years
4-5 years
more than 5 years
Never
8) How often do you study outside of class during the week?
0-3 hours
4-6 hours
7-9 hours
more than 9 hours
9) When Studying is alcohol involved?
Yes
No
10) When Studying is illegal drugs involved?
Yes
No
11) Do you ever drink alcohol before class?
Yes
No
*11b) If yes do you feel as though it helps you focus and/or improves your academic performance? (if no skip to question 12)
Yes
No
12) Do you ever use illegal drugs before class?
Yes
No
*12b) If yes do you feel as though it helps you focus and/or improves your academic performance? (if no skip to question 13)
Yes
No
13) Do you drink alcohol before a test?
Yes
No
14) Do you use illegal drugs before a test?
Yes
No

Thank you for your time and cooperation!