Pre Test
Burden
Disclosure Statement for References
Public
reporting burden for this collection of information is estimated to
average 25-minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda,
MD 20892-7974,
ATTN: PRA (0925-XXXX). Do not return the completed form to this
address.
The purpose of this questionnaire is to get some information about your knowledge, attitudes, and behaviors related to alcohol, alcohol use, driving under the influence of alcohol, and alcohol awareness education programs. It should take about 25 minutes to complete. PLEASE CIRCLE ONLY ONE ANSWER FOR EACH QUESTION, UNLESS THE QUESTION SAYS OTHERWISE. Please answer each question as best and as honestly as you can. Your responses are confidential, and your name will not be matched with your responses. Thank you for your time and participation in this important evaluation.
BIOGRAPHICAL INFORMATION
LAST 4 DIGITS OF YOUR PHONE NUMBER
**If no home phone number, please use locker number.
1. YOUR GRADE:
A. 10TH
B. 11TH
2. YOUR GENDER: A. Male
B. Female
3. RACE/ETHNICITY: A. American Indian or Alaska Native
B. Asian
C. Black or African American
D. Native Hawaiian or Other Pacific Islander
F. White
G. Caribbean Native
Ethnicity:
H. Hispanic or Latino
I. Not Hispanic or Latino
Knowledge Questions
Match
the various parts of the brain are responsible for the various
function:
______1. Cerebral Cortex A. Balance
______2. Amygdala B. Breathing
______3. Brain stem C. Fear
______4. Cerebellum D. Higher learning
5.
Neurons are the network of specialized cells within the
A
B C D
Heart Lungs Brain Kidney
6.
The synapse is the space between two:
A
B C D
Adjacent heart beats Adjacent neurons Adjacent lungs Adjacent blood vessels
8.
An
example of a neurotransmitter is:
A B C
D
Dopamine ADH Steroids TCH
9.
The organs of the body receive blood from the:
A
B C D
Arteries Nerves Veins Airways
10.
The organ responsible for drawing oxygen into the body is:
A B C D
Heart Lung Brain Kidney
11.
Cocaine stimulates the release of what brain chemical
(neurotransmitter)
A B C D
Oxygen Adrenaline Dopamine Carbon
12.
The way that cocaine causes stimulation is:
A.
Large amounts of dopamine leak out of the bloodstream
B. Brain
cells(neurons) absorb the excess dopamine, which causes the neurons
to be re-stimulated
C. It sends excessive amounts of oxygen
into the blood stream
D. It restricts the amount of dopamine
leaked out into the bloodstream
13. The "low"
of cocaine is caused by:
A.
Lowered dopamine stores in the brain
B. Lowered dopamine
stores in the heart
C. Lowered dopamine stores in the lung
D.
Lowered dopamine stores in the kidney
14.
Cocaine’s stimulant effect on the brain can lead to:
A B C D
Seizures
Muscle pain Trouble breathing Double vision
15. A
stroke can occur in a cocaine user when:
A.
Blood vessels in the heart expand
B. Blood vessels in the
brain constrict, causing decreased blood flow to a portion of the
brain
C. Too much oxygen is released into the bloodstream
D.
Too much alcohol is released in the bloodstream
16.
Cocaine can cause the following symptom:
A
B C D
Nosebleed Itchy
rash Hair Loss Yellow Skin
17. Cocaine causes
adrenaline release leading to:
A
B C D
Slowing
of the heart rate Memory loss Rapid and irregular heart
beating Decreased oxygen in the bloodstream
18.
Cocaine can cause a heart attack by:
A. Constricting a blood
vessel within the heart
B. Expanding a blood vessel within the
heart
C. Expanding blood vessels in the kidney
D. Causing
the lungs to collapse
19. Respiratory problems can result
from smoking cocaine by:
A.
Causing the airways of the lungs to widen
B. Causing the heart
to slow down
C. The lungs becoming overfilled with oxygen
D.
Causing the airways of the lungs to squeeze closed
20.
Bleeding within the brain after taking cocaine can be caused by
A.
A rapid rise in blood pressure causing blood vessels in the brain to
burst
B. A rapid decrease in blood pressure
C. A rapid
increase of oxygen levels in the blood
D. Dopamine entering the
brain and breaking down blood vessels
21.
Cocaine can cause which of the following problems pregnancy:
A.
Oversized baby
B. Bleeding
C. Too much oxygen for
the baby
D. Excess weight gain in mother
22.Marijuana
exerts its effects on the brain by:
A. Dissolving cannaboid
receptors
B. Binding to cannaboid receptors
C.
Multiplying cannaboid receptors
D. Dissolving opium
receptors
23. THC,the active component in marijuana is
:
A. A liquid
B. A molecule
C. A protein
D.
An acid
24.
Which areas of the brain contain large amounts of cannaboid
receptors?
A. Cerebellum(balance center)
B. Gyri
C. Spinal Cord
D.
Brain stem
25.
Marijuana can effect the eyes by:
A. Causing blindness
B.
Causing redness
C. Improving vision
D. Causing eye
pain
26. Smoking marijuana can increase risk of heart
attack by:
A. Lowering heart rate and blood pressure
B.
Increasing heart rate and blood pressure
C. Increasing
oxygen in blood
D. Increasing alcohol levels in blood
27.
Which of the following are increased with marijuana use:
A.
Stomach ulcers
B. Rashes
C. Lung tumors(cancer)
D.
Excess oxygen in the lungs
28. Lung effects of
marijuana use include:
A. Increased breathing
rate
B. Increased cough,phlegm and lung infections
C.
Increased oxygen in the lungs
D. Decreased number of
lung infections
29.
Marijuana weakens the immune system by:
A. Raising the body's
temperature
B. Decreasing the number of cells that fight
infection
C. Increasing the number of cells that fight
infection
D. Lowering the body's temperature
Drug use attitudinal questions
30. I believe using drugs is harmful to my health
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
31. I believe that drug use can have a negative impact on school performance.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
32. I would be comfortable refusing drugs if they were offered to me.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
33. I believe that drug use can have a negative impact on personal relationships.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
34. I believe that using drugs is okay every once and awhile.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
35. I believe that using drugs with friends is a good way to socialize on the week-ends.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
36. I believe that using drugs is part of growing up.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
Science Attitudinal Questions
37. I enjoy science classes
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
38. I would like to continue to take science classes after this year
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
39. I would like to study science after I graduate from high school
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
40. In the future, I would like to have a job that involves some type of science (ex. Nurse, XXX)
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
41. Science classes are fun
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
42. I like the activities we do in science class
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
43. Science classes are interactive
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
44. I see the benefit of studying science
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
45. I understand how science is a part of everyday life and the activities I participate in
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
46. I enjoy learning on the computer
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
47. I like using computers in school
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
48. I believe that computers can be good educational tools
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
49. Sometimes I get confused when using a computer
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
50. Using a computer based education is fun
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
Post Test
Burden
Disclosure Statement for References
Public
reporting burden for this collection of information is estimated to
average 25-minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda,
MD 20892-7974,
ATTN: PRA (0925-XXXX). Do not return the completed form to this
address.
The purpose of this questionnaire is to get some information about your knowledge, attitudes, and behaviors related to alcohol, alcohol use, driving under the influence of alcohol, and alcohol awareness education programs. It should take about 25 minutes to complete. PLEASE CIRCLE ONLY ONE ANSWER FOR EACH QUESTION, UNLESS THE QUESTION SAYS OTHERWISE. Please answer each question as best and as honestly as you can. Your responses are confidential, and your name will not be matched with your responses. Thank you for your time and participation in this important evaluation.
BIOGRAPHICAL INFORMATION
LAST 4 DIGITS OF YOUR PHONE NUMBER
**If no home phone number, please use locker number
1. YOUR GRADE:
A. 10TH
B. 11TH
2. YOUR GENDER: A. Male
B. Female
3. RACE/ETHNICITY: A. American Indian or Alaska Native
B. Asian
C. Black or African American
D. Native Hawaiian or Other Pacific Islander
F. White
G. Caribbean Native
Ethnicity:
H. Hispanic or Latino
I. Not Hispanic or Latino
Knowledge Questions
Match
the various parts of the brain that are responsible for the various
function:
______1. Cerebral Cortex A. Balance
______2. Amygdala B. Breathing
______3. Brain stem C. Fear
______4. Cerebellum D. Higher learning
5.
Neurons are the network of specialized cells within the
A
B C D
Heart Lungs Brain Kidney
6.
The synapse is the space between two:
A
B C D
Adjacent heart beats Adjacent neurons Adjacent lungs Adjacent blood vessels
8.
An
example of a neurotransmitter is:
A B C
D
Dopamine ADH Steroids TCH
9.
The organs of the body receive blood from the:
A
B C D
Arteries Nerves Veins Airways
10.
The organ responsible for drawing oxygen into the body is:
A B C D
Heart Lung Brain Kidney
11.
Cocaine stimulates the release of what brain chemical
(neurotransmitter)
A B C D
Oxygen Adrenaline Dopamine Carbon
12.
The way that cocaine causes stimulation is:
A.
Large amounts of dopamine leak out of the bloodstream
B. Brain
cells(neurons) absorb the excess dopamine, which causes the neurons
to be re-stimulated
C. It sends excessive amounts of oxygen
into the blood stream
D. It restricts the amount of dopamine
leaked out into the bloodstream
13. The "low"
of cocaine is caused by:
A.
Lowered dopamine stores in the brain
B. Lowered dopamine
stores in the heart
C. Lowered dopamine stores in the lung
D.
Lowered dopamine stores in the kidney
14.
Cocaine’s stimulant effect on the brain can lead to:
A B C D
Seizures
Muscle pain Trouble breathing Double vision
15. A
stroke can occur in a cocaine user when:
A.
Blood vessels in the heart expand
B. Blood vessels in the
brain constrict, causing decreased blood flow to a portion of the
brain
C. Too much oxygen is released into the bloodstream
D.
Too much alcohol is released in the bloodstream
16.
Cocaine can cause the following symptom:
A
B C D
Nosebleed Itchy
rash Hair Loss Yellow Skin
17. Cocaine causes
adrenaline release leading to:
A
B C D
Slowing
of the heart rate Memory loss Rapid and irregular heart
beating Decreased oxygen in the bloodstream
18.
Cocaine can cause a heart attack by:
A. Constricting a blood
vessel within the heart
B. Expanding a blood vessel within the
heart
C. Expanding blood vessels in the kidney
D.
Causing the lungs to collapse
19. Respiratory problems can
result from smoking cocaine by:
A.
Causing the airways of the lungs to widen
B. Causing the heart
to slow down
C. The lungs becoming overfilled with
oxygen
D. Causing the airways of the lungs to squeeze closed
20.
Bleeding within the brain after taking cocaine can be caused by
A.
A rapid rise in blood pressure causing blood vessels in the brain
to burst
B. A rapid decrease in blood pressure
C. A
rapid increase of oxygen levels in the blood
D. Dopamine
entering the brain and breaking down blood vessels
21.
Cocaine can cause which of the following problems pregnancy:
A.
Oversized baby
B. Bleeding
C. Too much oxygen for
the baby
D. Excess weight gain in mother
22.Marijuana
exerts its effects on the brain by:
A. Dissolving cannaboid
receptors
B. Binding to cannaboid receptors
C.
Multiplying cannaboid receptors
D. Dissolving opium
receptors
23. THC,the active component in marijuana is
:
A. A liquid
B. A molecule
C. A protein
D.
An acid
24.
Which areas of the brain contain large amounts of cannaboid
receptors?
A. Cerebellum(balance center)
B. Gyri
C. Spinal Cord
D.
Brain stem
25.
Marijuana can effect the eyes by:
A. Causing blindness
B.
Causing redness
C. Improving vision
D. Causing eye
pain
26. Smoking marijuana can increase risk of heart
attack by:
A. Lowering heart rate and blood pressure
B.
Increasing heart rate and blood pressure
C. Increasing
oxygen in blood
D. Increasing alcohol levels in blood
27.
Which of the following are increased with marijuana use:
A.
Stomach ulcers
B. Rashes
C. Lung tumors(cancer)
D.
Excess oxygen in the lungs
28. Lung effects of
marijuana use include:
A. Increased breathing
rate
B. Increased cough,phlegm and lung infections
C.
Increased oxygen in the lungs
D. Decreased number of
lung infections
29.
Marijuana weakens the immune system by:
A. Raising the body's
temperature
B. Decreasing the number of cells that fight
infection
C. Increasing the number of cells that fight
infection
D. Lowering the body's temperature
Drug use attitudinal questions
30. I believe using drugs is harmful to my health
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
31. I believe that drug use can have a negative impact on school performance.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
32. I would be comfortable refusing drugs if they were offered to me.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
33. I believe that drug use can have a negative impact on personal relationships.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
34. I believe that using drugs is okay every once and awhile.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
35. I believe that using drugs with friends is a good way to socialize on the week-ends.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
36. I believe that using drugs is part of growing up.
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
Science Attitudinal Questions
37. I enjoy science classes
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
38. I would like to continue to take science classes after this year
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
39. I would like to study science after I graduate from high school
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
40. In the future, I would like to have a job that involves some type of science (ex. Nurse, XXX)
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
41. Science classes are fun
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
42. I like the activities we do in science class
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
43. Science classes are interactive
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
44. I see the benefit of studying science
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
45. I understand how science is a part of everyday life and the activities I participate in
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
46. I enjoy learning on the computer
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
47. I like using computers in school
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
48. I believe that computers can be good educational tools
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
49. Sometimes I get confused when using a computer
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
50. Using a computer based education is fun
A B C D E
Strongly Agree Agree Neutral Disagree Strongly Disagree
| File Type | application/msword |
| Author | jill graygo |
| Last Modified By | curriem |
| File Modified | 2009-03-17 |
| File Created | 2009-03-17 |