Prescreening Questions For Adult Lifestyle Survey

To see whether you are qualified for this survey, we have to ask you some questions. It takes only two minutes.

  1. How old are you?
  2. Gender: Male Female
  3. Do you currently smoke? Yes No
  4. How many cigarettes do you normally smoke per day?
  5. What age did you begin smoking?
  6. How many drinks do you normally drink per sitting?
  7. How many days per week do you normally drink?

The next questions are about your life style. Could you rate each statement in a scale of 0 to 9? (0 - being not like me at all and 9 - being very much like me)

   
NOT AT All Like Me                                                                                    Very Like ME


0       1      2      3      4      5      6      7      8      9

 

Your Answer

  • I like people who are partiers.

0 1 2 3 4 5 6 7 8 9

  • I’m likely to do drink when I want to party.

0 1 2 3 4 5 6 7 8 9

  • I am at a party with other people. Someone lights a joint of marijuana and begins to pass it around the party. A lot of people are trying it. I will try it.

0 1 2 3 4 5 6 7 8 9

  • Having lots of alcohol is the key to a really good party.

0 1 2 3 4 5 6 7 8 9

  • I like wild and uninhibited parties.

0 1 2 3 4 5 6 7 8 9

  • I am rebellious

0 1 2 3 4 5 6 7 8 9

 

If you are chosen, you will be invited to answer some questions after viewing some media messages. You will be paid $10 for this one time opportunity. The session will take approximately one hour. The session will be held on Nov. 18 at 6:50 PM in Murrow. Please bring your id with you, so we know who you are. Feel free to contact us if you have any questions.

Name:

Telephone Number

Email:

 

Thank you very much for your interest. We will contact you shortly.