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Which of the 14 PASSHE Universities are you currently attending?

Bloomsburg

School year status:

1st year

How would you describe your current academic status?

Full time (12 or more credits undergrads; 9 or more grad students)

Have you transferred to this school within the past 12 months?

Yes

What is your overall grade point average?

1,234.5

Have you participated in any of the following athletics-related activities (Mark all that apply)?

College/University athletic team

Have you participated in any of the following non-athletic activities while in college (Mark all that apply)?

Honors Program

Do you currently have a job?

Yes- full time (40 hours or more/wk)

Describe your source of healthcare insurance:

College/university sponsored plan

Describe your living arrangement:

On campus resident hall

Where is your permanent residence?

In state

What is your gender?

Female

What is your current age?

1,234

How do you describe your racial and ethnic background?

African American/Black

Describe your marital status:

Single

Are you currently taking any prescription medications other than those used to treat a cold or for birth control?

Yes

Do you have any blood relatives that have or had alcohol or other drug use problems?

Yes alcohol

How often do you think the average student on your campus drinks alcoholic beverages?

Never

How many drinks of alcohol do you think the average student on your campus has on a typical day (24 hour period) when drinking?

1 or 2

How often do you think the average student on your campus has six or more drinks in one occasion?

Never

What percentage of students do you suspect have tried marijuana?  (Please use a whole number between 0 and 100 where 0 means 0% and 100 means 100%)

123,400 %

On your campus how often do you think someone who says they use marijuana actually uses it?

Never

How often do you have any drinks containing alcohol?

Never

How many drinks of alcohol do you have on a typical day (24 hour period) when you are drinking? **SKIP IF YOU NEVER DRANK**

1 or 2

How often do you have six or more drinks on one occasion?

Never

How often during the last year have you found that you were not able to stop drinking once you had started?

Never

How often during the last year have you failed to do what was normally expected of you because of drinking?

Never

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

Never

How often during the last year have you had a feeling of guilt or remorse after drinking?

Never

How often during the last year have you been unable to remember what happened the night before because of your drinking?

Never

Have you or someone else been injured because of your drinking?

No

Has a relative, friend, doctor or other health care worker been concerned about your drinking or suggested you cut down?

No

If you have consumed alcohol, how old were you when you first tried alcohol?

Non-Applicable

When you drink, it is at/in: **CHECK ALL THAT APPLY**

your dorm room, friend’s dorm room, your off campus apartment

What are your reasons for your drinking? **CHECK ALL THAT APPLY**

escape from problems, go dancing, go to parties

For the following question please indicate the answer that best describes your thoughts or behaviors toward your use of alcohol.

I never think about my drinking

Have you used drugs other than those required for medical reasons?

Yes

Do you abuse more than one drug at a time (e.g. use a drug in combination with alcohol)?

Yes

Are you unable to stop using drugs when you want to?

Yes

Have you ever had blackouts or flashbacks as a result of drug use?

Yes

Do you ever feel bad or guilty about your drug use?

Yes

Do your parents (or friends) ever complain about your involvement with drugs?

Yes

Have you neglected your family as a result of your drug use?

Yes

Have you engaged in illegal activity to obtain drugs?

Yes

Have you experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

Yes

Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

Yes

Caffeine (energy drinks, No-Doz, coffee, etc.)

Never

Cigarettes or Tobacco products

Never

Inhalants Nitrous, whip-its, paint, aerosols, etc.

Never

Bath salts

Never

K2, Spice or another synthetic marijuana product

Never

Amphetamines (e.g. Adderal, Ritalin)

Never

Pain pills (Oxycodone, Oxycontin, Codeine, Lortab etc.)

Never

Medications for anxiety (Valium, Xanax, Klonopin, etc.)

Never

Sleep aids (Ambien etc.)

Never

Steroids

Never

Cocaine and/or crack cocaine

Never

Ecstasy (MDMA, Molly, etc.)

Never

Heroin

Never

LSD or Acid

Never

Marijuana/Has/Hash oil

Never

Methamphetamine (Ice)

Never

Psychedelic Mushrooms

Never

Salvia

Never

Please list and indicate your use history below if applicable

Never

At what age did you first try caffeine?

Non Applicable

At what age did you first try a tobacco product (chew, cigarettes, etc.)?

Not Applicable

At what age did you first try marijuana or another form (hash, has oil, etc.)?

Not Applicable

At what age did you first try any form of an inhalant (gasoline, nitrous, paint, etc)?

Not Applicable

When you use other drugs it is at/in: **MARK ALL THAT APPLY**

your dorm room, friend’s dorm room, your off campus apartment

What are your reasons for using drugs? **MARK ALL THAT APPLY**

escape from problems, go dancing, go to parties

For the following question please indicate the answer that best describes your thoughts or behaviors toward your use of other drugs.

I never think about my use of other substances

Had money problems due to drinking or drug usage?

No

Affected your grades?

No

Affected your work (missed hours etc.)?

No

Missed a class?

No

Did not complete an assignment on time due to drinking/drug use?

No

Gotten a traffic ticket?

No

Had a car crash?

No

Driven with someone who has      been drinking?

No

Gotten arrested?

No

Gotten in trouble at school (citation etc.)?

No

Blacked out (memory loss)?

No

Taken care of a roommate that has passed out?

No

Broken a bone?

No

Passed out?

No

Hurt someone else?

No

Been physically abused by someone you know?

No

Been sexually abused by someone you know?

No

Had hangovers?

No

Hurt yourself?

No

Engaged in unsafe sexual activity?

No

Were required to have medical treatment from drinking or drug use?

No

Damaged a friendship?

No

Engaged in unplanned sexual activity?

No

Became angered at others while intoxicated?

No

Became overly emotional with others?

No

Have you read your campus’ code of conduct rules?

Yes

Did you attend a judicial presentation during orientation?

Yes

Have you visited the campus health center?

Yes

Are you currently in Alcoholics Anonymous (AA)/Narcotics Anonymous (NA) or another program?

Yes

Does your campus have resources for conversations about alcohol and drugs?

Yes

Are you aware of the Medical Amnesty Act (Good Samaritan Act) passed by PA legislation?

Yes

Have you ever called police/medical help for yourself?

Yes

Have you ever called police/medical help for someone else?

Yes

Have you ever not called police/medical help for someone but felt that you should have?

Yes

Created at 7/27/2016 8:48 PM by
Last modified at 7/27/2016 8:48 PM by