Survey for MIDDLE SCHOOL Students and Adults who recently saw our DWI Program

Program Date: School: City:

Age: _____ Sex: ____Male, ___Female Grade:

Race / Ethnicity: Asian___ Black___ Hispanic ___ Native American___ White___Other_______

1. What is the legal age for consuming alcohol in the State of Texas? ___17, ___ 18, ___19, ___20, ___ or ___ 21 & over

2. The illegal blood alcohol level (B.A.C.) for a Texas Driver 21 & older is? ___.05, ___.06, ___.07,___ .08, ___.09, ___.10

3. How long does it take for alcohol to take effect once you drink it?

_____ A. Immediately _____ B. 30 mins _____ C.1 hr _____ D. 2 hrs _____ E. Depends on the type Alcohol

4. If the person taking you home from a party was intoxicated or under the influence of drugs, what would you do?

_____A. Ride home with them anyway _____ C. Call home for a family member to pick you up ____ E. Drive for them

_____B. Call a Sober Friend to pick you up _____ D. Get a ride from another person at the party ____ F. Call A Taxi Cab

5. Prior to seeing this DWI program did you wear your Seat Belt? (Be Honest)

_____ A. Never _____ B. Yes, When reminded _____ C. Only when I think about it _____ D. Always

6. If never, will you use your seat belt after seeing the DWI Program? ___YES ____NO or ____ N/A, if you always wear it

7. Did you wear your seat belt today? ___ YES ___ NO

8. Have you ever ridden with someone that you knew had been consuming alcohol or drugs? ___ YES ___ NO

If yes, after seeing what can happen, would you ride with someone again that’s been drinking of doing drugs? _YES _NO

9. If you witnessed Drugs or Alcohol at a party, knowing it’s illegal to be there, would you stay or leave? __Stay __Leave __Not Sure

10. What did you think about the DWI Alcohol Awareness Program you just saw? Please check only one.

____ I was forced to attend and got nothing from it, and felt it was a waste of my time.

____ It had some impact on my views about drinking and driving.

____ It made a major impact and has changed my views on drinking and driving.

11. Please circle a RATING for each area you saw or heard that helped change your mind about Driving under the Influence

Seeing the actual crash pictures. (poor) 1 2 3 4 5 (very good)

Hearing an emergency call. (poor) 1 2 3 4 5 (very good)

Hearing stories from people involved in DWI crashes! (poor) 1 2 3 4 5 (very good)

Memory section of lost loved ones. (poor) 1 2 3 4 5 (very good)

The legal and statistical information. (poor) 1 2 3 4 5 (very good)

Crash Car Display (poor) 1 2 3 4 5 (very good)

12. Please RATE our DWI PROGRAM as a whole: (poor) 1 2 3 4 5 (very good)

13. What one thing about the DWI program was most valuable to you?

14. What could we do to make the program better?

15. Any Additional Comments?

Our goal is to Educate and Save Lives!

16. Put a CHECK by any of the substances you have tried and/or are currently using, and circle how often. (Be honest with yourself)

Never Tried Any Drugs or Alcohol Beer [Once / Daily / Weekly / Monthly / Past] Cocaine [Once / Daily / Weekly / Monthly / Past]

Cigarettes [Once / Daily / Weekly / Monthly / Past] Wine [Once / Daily / Weekly / Monthly / Past] Heroin [Once / Daily / Weekly / Monthly / Past]

Snuff [Once / Daily / Weekly / Monthly / Past] Liquor[Once / Daily / Weekly / Monthly / Past] Ecstasy [Once / Daily / Weekly / Monthly / Past]

Marijuana [Once / Daily / Weekly / Monthly / Past] Acid [Once / Daily / Weekly / Monthly / Past] Meth [Once / Daily / Weekly / Monthly / Past]

Huffing [Once / Daily / Weekly / Monthly / Past] Crack [Once / Daily / Weekly / Monthly / Past] Shrooms [Once / Daily / Weekly / Monthly / Past]

Other (List) XBars [Once / Daily / Weekly / Monthly / Past] Speed [Once / Daily / Weekly / Monthly / Past]

"Texas Law for anyone Under 21 is ZERO TOLERANCE THAT MEANS ZERO ALCOHOL & DRUGS"

Danger Without Intentions, 1207 Peach Creek Road, Waelder, Texas 78959, Updated: 01/20/2011

Toll Free Number 1-866-893-2821 or www.dangerwithoutintentions.com