Hello, my name is Professor Sierminski and this is my happy, yet handy, little assistant, Kiah.

PEER PRESSURE SURVEYS:

The purpose of this survey is to collect information from you about peer pressure.With your experience and information, we can help advise and turn you into the right direction.

This survey is divided into the following sections:

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information, and submit the form. You will receive a confirmation message from us shortly.

SECTION A -- Drug Abuse

Click in the box or answer in your own words.

  1. What do you consider the greatest danger of using drugs?



  2. How many times have you ever tried drugs?

    None 1-5 times 5-10 times 10-20 times More than 20 times

  3. We would like to send you your results. What is your e-mail address? 
    Name     
e-mail
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SECTION B -- Smoking

The instructions are the same as the last section

  1. Have you ever tried smoking?

    Yes No

  2. Were you pressured into this or was this your decison?




  3. Please describe your experience with smoking

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SECTION C -- Guns and Weapons

 

  1. Do you or any one of your friends currently own a gun or weapon? 
    YES    
NO
  2. Please enter any comments regarding your experience with guns or weapons:



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FORM SUBMISSION

Thank you for taking the time to answer the questions in our survey.

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This explains how we plan to use the information you provide to us. We will also explain what benefits you receive from helping us in this way.

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