The Cut: Pre Survey (Print)

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 but keep it to yourself. Thanks.
Pick a nick name ___________________________________
What's the name of your school? _______________________________________________________

What's the staff person's name who is 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

_____ Health

_____ Friends

_____Dating

_____School

_____Fun
_____Future

_____Independence

_____Family

_____Popularity

_____Music

_____Sports

PRE SURVEY
THE CUT™ (VER 3-04)

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
Most times do you take the lead or follow others? lead         follow
Does smoking cause lung cancer? yes         no
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 2 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?

Please return this form to the staff person.

**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 but keep it to yourself. Thanks. Pick a nick name ___________________________________ What's the name of your school? _______________________________________________________ What's the staff person's name who is 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 _____ Health _____ Friends _____Dating _____School _____Fun	_____Future _____Independence _____Family _____Popularity _____Music _____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 Most times do you take the lead or follow others? lead follow Does smoking cause lung cancer? yes no 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 2 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?
Please return this form to the staff person.