Form G Survey

OMB #: 0925-0542

Expiration Date: 4-30-08

Form G

Brain Power! Challenge

Grades 6-9

Part A: Student Knowledge Questionnaire

DIRECTIONS: Please fill in the best answer, unless instructed to do otherwise. Remember to fill in your response darkly and completely like this: 

MODULE 1

1. This part of the brain…

• Is divided into a left and a right hemisphere

• Is the largest part of the brain

• Is responsible for artistic expression, thinking, and understanding (things like solving a problem and reading a map)

Which part is it?

• Cerebellum

• Brain stem

• Limbic system

• Cerebral cortex

2. This part of the brain…

• Means “little brain”

• Controls posture, movement, and balance

• Is used when you play catch

Which part is it?

• Cerebellum

• Brain stem

• Limbic system

• Cerebral cortex

3. This part of the brain…

• Controls almost every function of the body that keeps us alive like breathing, heart rate, and blood pressure

• Controls reflexes like sneezing

• Controls sleeping, waking, and dreaming

Which part is it?

• Hypothalamus

• Limbic system

• Cerebral cortex

• Brain stem

4. This part of the brain…

• Is located deep within the center of the brain

• Is the size of a pea

• Helps keep our body temperature at 98.6 degrees

• Tells us when we are hungry or thirsty

Which part is it?

• Hypothalamus

• Limbic system

• Cerebral cortex

• Brain stem

5. What is the name of the special nerve cells in the brain that are responsible for carrying information to and from the body and other parts of the brain?

• Neurons

• Synapses

• Receptors

• Frontal lobe

MODULE 2

6. Which of the following about smoking is true?

• Smoking is not as harmful as chewing tobacco.

• Smoking increases the senses of smell and taste.

• Health problems linked to smoking include cancer, emphysema, and gastric ulcers.

• It is easy to quit smoking.

7. Which of the following about nicotine is true?

• Nicotine acts like and is shaped like another neurotransmitter in the brain so its fits into the same receptors, fooling the brain.

• Nicotine causes a decrease in the release of dopamine.

• Nicotine is less addictive than heroin or cocaine.

• Nicotine causes a decrease in blood pressure, heart rate, and respiration.

8. What is the name of the neurotransmitter that nicotine acts upon?

• Occipital

• Acetylcholine

• GABA

• Methylphenidate

MODULE 3

9. This class of drugs…

• Is prescribed for pain

• Includes codeine, vicodin, and morphine

• Can lead to addiction, respiratory problems, and death if used inappropriately

• Causes increased drowsiness

Which class of drugs is it?

• Opioids

• Dopamines

• Stimulants

• Inhalants

10. This class of drugs…

• Is prescribed for ADHD and depression

• Includes dexedrine and ritalin

• Can lead to irregular heart beat, heart attack, seizures, and high body temperature if used inappropriately

Which class of drugs is it?

• Opioids

• Dopamines

• Stimulants

• Inhalants

11. This class of drugs…

• Deprives the brain of oxygen

• Includes chemical fumes found in some household products

• Can cause “sudden sniffing death”

Which class of drugs is it?

• Opioids

• Dopamines

• Stimulants

• Inhalants

MODULE 4

12. Marijuana comes from the dried leaves and flowers of which plant?

• Coca plant

• Cannabis

• Poppy

• Rosy periwinkle

13. Activity in a certain part of the brain is reduced when someone is using marijuana and it causes problems with short-term memory. Which part is it?

• Frontal lobe

• Hippocampus

• Hypothalamus

• Medula

MODULE 5

14. Heroin activates something in the brain, which increases the amount of dopamine released and results in a short-lived rush. What is it that heroin activates?

• Synapses

• Axons

• Opiate receptors

• Parietal lobes

15. What does cocaine prevent from happening during neurotransmission?

• The movement of dopamine back into the first neuron, so it stays in the synapse

• The exchange of information between axons and dendrites

• The movement of messages from nerve signals

• The binding of neurotransmitter to receptor

16. Which of the following about cocaine is true?

• It causes blood vessels to expand, rushing the flow of blood within the body.

• It causes decreases in heart rate, blood pressure, and breathing.

• It activates the brain’s reward system.

• It comes from poppy seeds.

MODULE 6

17. This drug…

• Is an illegal stimulant used to speed up the brain’s functioning

• Is produced as pills, powders, or chunky crystals called ice

• Can result in heart failure from overdose

• Is produced in home-based labs

Which drug is it?

• Methamphetamine

• Steroids

• Ecstasy

• Ketamine

18. This drug…

• Can be used legally as anesthesia for animals during veterinary surgeries

• Comes in liquid and powder forms

• Causes users to experience hallucinations, numbness, slurred speech, and breathing problems

• Is a “club drug”

Which drug is it?

• Methamphetamine

• Steroids

• Ecstasy

• Ketamine

19. Which of the following about “club drugs” is true?

• MDMA causes decreases in heart rate and blood pressure.

• Methamphetamine is not a “club drug.”

• “Club drug” symptoms include drowsiness and memory loss that can last up to 12 hours.

• Ketamine is a legal anesthetic used in surgery on people.

20. Drugs only affect the person who uses them?

• True

• False

Part B. Student Attitudes Questionnaire

Please fill in one bubble for your answer to each question. Remember to fill in your response darkly and completely like this: 

First, please tell us about yourself.

1. What grade are you in?

• 6th grade

• 7th grade

• 8th grade

• 9th grade

2. How old are you?

• 10–11

• 12–13

• 14–15

• 16–17

• 17 or older

3. Are you a…

• Male

• Female

4. Are you… (Fill in one bubble.)

• White

• Black or African American

• American Indian

• Hispanic or Latino

• Asian

• Other

5. These questions ask about what you think about alcohol. Alcohol includes beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. (Fill in one bubble for each line.)

	Strongly agree	Agree	Not sure	Disagree	Strongly disagree
a. Drinking alcohol can keep a person’s mind off his/her problems at home.					
b. Teenagers drink in order to get attention.					
c. A person may have a few drinks of alcohol in order to be part of the group.					
d. People are more sure of themselves when they are drinking alcohol.					
e. Most alcohol tastes terrible.					
f. People feel less lonely when they drink alcohol.					
g. Alcoholic beverages make parties more fun.					

6. During the last 12 months, how often have you…

	Never	1–2 times	3–9 times	10–19 times	20 or more times
a. Had a drink of alcohol (other than a few sips)					
b. Gotten drunk or sick from alcohol					

7. Why do you like to drink? (Fill in all that apply.)

• I don’t like to drink

• I drink because it seems like everyone else is

• I drink so I can feel a little tipsy

• I drink so I can experience being drunk

8. How many of your friends drink alcohol?

• None

• A few

• Most of them

• All of them

9. Has your drinking alcohol ever caused you any of the following problems? (Fill in one bubble for each line.)

	No	1-2 times	3–9 times	10 or more times
a. Gotten you in trouble at school?				
b. Hurt your school work?				
c. Gotten you in fights with other kids?				
d. Gotten you in fights with your parents?				

10. These questions will tell us what you think about nicotine, which is used in cigarettes and in chewing tobacco (also called dip or chew). (Fill in one bubble for each line.)

	Strongly agree	Agree	Not sure	Disagree	Strongly disagree
a. Smoking cigarettes is OK as long as someone doesn’t smoke very often.					
b. Chewing tobacco (such as Redman, Beechnut, Skoal, Skoal Bandit, or Copenhagen) is OK as long as someone only chews a little.					
c. Smoking cigarettes is a nasty habit.					
d. It is easy to quit smoking.					
e. Teenagers smoke because they think it makes them look cool.					
f. Many of my friends smoke cigarettes.					

11. Have you ever smoked cigarettes?

• Yes

• No

12. How often do you smoke cigarettes?

• I don’t smoke

• Once or twice a year

• Once or twice a month

• Once or twice a week

• Every day

These questions will tell us what you think about inhalants, like those found in household products. (Fill in one bubble  for each question.)

13. Have you ever sniffed (or “huffed”) glue, gas, sprays, or anything like that to get high?

• Yes

• No

14. During your lifetime, how many times have you sniffed (or “huffed”) glue, gas, or anything like that to get high?

• Never

• 1–2 times

• 3–9 times

• 10 or more times

15. How many of your friends sniff (or “huff”) glue, gas, or anything like that to get high?

• None

• A few of them

• Most of them

• All of them

16. These questions tell us what you think about illegal drugs such as marijuana, cocaine, heroin, and steroids. (Fill in one bubble  for each line.)

	Strongly agree	Agree	Not sure	Disagree	Strongly disagree
a. It is stupid to try illegal drugs.					
b. Marijuana is not as bad as other illegal drugs.					
c. Steroids help athletes perform better.					
d. A person can try cocaine a couple times and not worry about getting addicted.					
e. A person who is going through heroin withdrawal will do just about anything to get more of it.					
f. Cocaine helps people have more energy.					
g. It’s okay to try crystal meth one time just to see what it feels like.					
h. Club drugs seem OK, as long as you just use them for fun once in awhile.					

17. These questions tell us what you think about prescription drugs. (Fill in one bubble  for each line.)

	Strongly agree	Agree	Not sure	Disagree	Strongly disagree
a. Even if a doctor prescribes a drug for you, taking too much of it can hurt you.					
b. Taking someone else’s Ritalin is dangerous.					
c. Prescription drugs can be shared with family members.					

18. Have you ever tried marijuana (also called weed or pot)?

• Yes

• No

19. During your lifetime, how many times have you smoked or eaten marijuana (weed or pot)?

• Never

• 1–2 times

• 3–9 times

• 10 or more times

20. Why do you use marijuana (weed or pot)?

• I don’t use it

• I smoke just a puff or eat just a bite to see what it feels like

• I smoke or eat just enough to feel a little high

• I smoke or eat enough to feel high

21. How many of your friends use marijuana (weed or pot)?

• None

• A few

• Most of them

• All of them

22. Have you ever tried any of the following drugs? (Fill in one bubble  for each line.)

	Yes	No
a. Crack		
b. Cocaine		
c Ketamine (“Special K”)		
d. Heroin		
e. Methamphetamines (crystal meth, ice, crank)		
f. Ecstasy		
g. Other club drugs (GHB, roofies)		

23. If one of your friends asked you to try any one of the following drugs, how easy or hard would it be for you to say no? (Fill in one bubble  for each line.)

	Easy to say no	Hard to say no	I wouldn’t say no because I’d be embarrassed	I wouldn’t say no because I would want to do it
a. Alcohol				
b. Cigarettes, dip, or chew				
c. Marijuana				
d. Prescription drug that was not yours				
d. Cocaine or heroin				
e. Crystal meth or other club drug				
f. Steroids				

24. If one of your friends wanted to try any of the drugs above, how easy or hard would it be for you to stop him or her from doing it?

• Easy to stop my friend

• Hard to stop my friend

• I wouldn’t be able to stop my friend

25. Which of the statements below best describes you? (Do not count alcohol or tobacco use for this question.)

I have…

• Never used illegal drugs and never will

• Never used illegal drugs but may in the future

• Used illegal drugs but don’t plan to use them again

• Used illegal drugs and probably will use them again

THANK YOU