JACS TEEN SURVEY
PLEASE TELL US:
DO NOT
WRITE YOUR NAME ON THIS PAPER ñ THE ANSWERS ARE FOR
THE EXCLUSIVE
USE OF JACS & ARE ONLY USED TO INFORM OUR PROGRAMS.
1.
What
problem(s) are the biggest concern(s) to people in your age group?
Please grade each of the following from 1-5
Circle the appropriate number:
(1 = Not a problem / 5 = A big problem)
drugs
1 2 3 4 5 college
admission/grades 1 2 3 4 5
alcohol
1 2 3 4 5 parent
pressure
1 2 3 4 5
gambling
1 2 3 4 5 food
(anorexia/bulemia) 1 2 3 4 5
cigarettes
1 2 3 4 5
other ( please specify)
_______________________________
2.
Do you have any friends in trouble with drugs or the other ìriskyî
behaviors listed above?
Yes_____
No______ If yes, have you
tried to help? How?
3.
Have you tried any of the following illicit street drugs?
Marijuana
Never___ Once___ Twice____ Other_____
Cocaine
Never___ Once___
Twice____ Other___
Heroin
Never___ Once___ Twice____
Other___
Ecstasy
Never___ Once___ Twice____
Other___
Inhalents
Never___ Once___ Twice____
Other___
Other_________________________
What about Alcohol?_____________________________
4.
Do you think knowing the dangers of drinking, drug use, eating disorders,
gambling would influence someone to stop using?
Yes_____
No______
5.
Does being involved Jewishly affect whether people use drugs, drink,
etc.?
Yes_____ No______
6.
Is there any adult in your life that you could go to if you got into
trouble with any of these behaviors?
Yes_____
No______
7.
If
you have attended a JACS program, did
you learn anything new from the program or did it change your thinking about anything?
( Please explain briefly)
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
8. Was there anything
in the session that caused you to think about
something in your life?________________ ( Please explain briefly)
________________________________________________________
________________________________________________________
________________________________________________________
9.
Use this space to add any comments.
If you would like someone to
contact
you, write your name and phone number, address or e-mail
address below. You can copy this entire page with your answers and
send
it to JACS. Paste it into an e-mail or fax or snail mail it.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
To contact JACS: 212-397-4197 Fax: 212-399-3525
jacs@jacsweb.org
www.jacsweb.org