PRE SURVEY
THE CUT™ (VER 3-04)

We would like to know how we can make a better program. We need your help to do this. Please be as honest as you can when you fill out the following form. We don't need to know your real name. Just pick a nick name and remember it for later (write it down but keep it to yourself). Thanks.

Make up a nick name
What's the name of your school?
Who is the staff person leading this class?

Which of the following things are most important to you? Which is second and third in importance? (Put a 1 next to the most important, a 2 next to the second most important and a 3 next to the third most important.)
  Money   Future
  Health   Independence
  Friends   Family
  Dating   Popularity
  School   Music
  Fun   Sports


Do you smoke? yes no
Ever tried a cigarette or chewing tobacco? yes no
Own any hats, jackets, wallets or other things with cigarette brands on them? yes no
Do you usually buy things because you see them advertised? yes no
Do your parents smoke? yes no
Do any of your brothers or sisters smoke? yes no
Do any of your friends smoke? yes no
Does smoking cause lung cancer? yes no
Most times do you take the lead or follow others? lead follow

If there was a 'good excuse' to smoke what would it be?

Can smoking cause health problems? not really maybe sometimes always

Can you become addicted to smoking if you only smoke 1 cigarettes a day? yes no

Why do kids smoke?

How likely is it that you would try a smoke? not very a little pretty likely very likely

How often do you use a computer? not much a little quite a bit a lot

Do you have a favorite Web site or computer game ?
(Write the name of site or game below.)

What do you think of kids who smoke?

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