Survey on Smoking

Megan Sharkey

This survey is voluntary. Your answers will be confidential, and you will remain anonymous. Thank you for taking your time to fill this out!

1. Do you currently smoke? Yes  No

2. Have you ever smoked? Yes  No

 

Please indicate your level of agreement on the following items. Circle one per item only. 1 = Strongly Disagree 2 = Disagree 3 = Not Sure 4 = Agree 5 = Strongly Agree

3. Smoking should be banned inside all restaurants. 1 2 3 4 5

4. Smoking should be banned inside all workplaces. 1 2 3 4 5

5. Smoking should be banned inside all clubs. 1 2 3 4 5

6. Second-hand smoke is harmful to non-smokers. 1 2 3 4 5

7. Smoking should be banned in all public places? 1 2 3 4 5

8. Briefly provide some reasons why you feel the way you do about #7.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

9. If you have ever smoked and have now quit – what was the reason you quit? (check all that apply).

    __ peer pressure

    __ personal concern for health

    __ pressure from family

    __ increased restriction on smoking in public

    __ I have never smoked

    __ other: (please explain)

10. If you currently smoke, what has kept you from quitting? (check all that apply)

     __ I enjoy it

     __ unable to quit, but want to

     __ one or more in my household smokes

     __ many of my friends smoke

     __ under too much stress

     __ I don’t smoke

     __ other: (please explain)

11. Name the top 4 diseases caused by excessive smoking. If you can't name any or all of them, leave the spaces blank. 

#1. _________________________________________________________

#2. _________________________________________________________

#3. _________________________________________________________

#4. _________________________________________________________

12. How many new smokers under the age of 18 are there each year? (check one only)

___under 1000

___5,000-50,000

___100,000-200,000

___500,000-1,000,000

__over 1,000,000

12. What is your age? _____years

13. What is your gender? Male Female

14. What is your race? (check one)

     __ White

     __ American Indian

     __ African-American

     __ Alaskan Native

     __ Hispanic/Latino

     __ Asian American

     __ Other

Thanks for participating!

 

Internet Survey

Cristy Kolwe

Hello, and thanks for participating. This survey is designed to find out your ideas and concerns about the Internet. Please answer each question as accurately as possible. This survey is voluntary and confidential. Your identity will not be revealed publicly on any of the items to which you respond.

Section No. 1

Directions: Please circle or check ONLY ONE answer for each question unless stated otherwise.

1. The government should have the authority to pass laws concerning privacy on the Internet.

NO! NO no ? yes YES YES!

2. The reason(s) I believe the way I do about the government and Internet privacy is/are because:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

3.  In an average WEEK (Sun-Sat) how often do you use the Internet? (Check only one.)

___Never   ___1 Time Week   ___2-4 times per week    ___5+ times a week

4.  Have you ever provided ANY of the following information to an ONLINE source in order to make a purchase of the Internet? (Circle all that apply.)

first/last name  street address   zip code   home phone #   office phone #

social security #   credit card #   bank card #   drivers license #

Section II: Demographics

5. What is your class level?    Freshman    Sophomore    Junior    Senior

 

6. What is your sex?   Male   Female

 

7. What is your age?  _____ years

 

Safe Sex Survey

Annette Darling

 

NOTE: This survey is entirely voluntary and confidential. Your individual identity will not be made public in respect to any of the following survey items.

Directions: Please indicate your level of agreement on the following statement:

1 = strongly disagree    2 = disagree    3 = not sure    4 = agree    5 = strongly agree

1.   All persons who engage in sexual activity exclusively for pleasure should use birth control with spermicidal lubricant. (circle one number only)     

      1    2    3    4    5

 

2.       Why do you believe the way you do about the above statement? Briefly note reason(s) here:

____________________________________________________________________

____________________________________________________________________

           ____________________________________________________________________

 

3.       Rank the following from items from 1-4, with 1 being your first choice and four being your last:

Birth control should be used primarily for:

_____  Pregnancy prevention

_____  Disease Prevention

_____  Shouldn’t Be Used

_____  Other (List) _______________________

 

4.  How many times per month do you engage in sexual intercourse for pleasure only? ___________

 

5.  How many times have you used birth control with spermicidal lubricant during those times of intercourse? ___________

 

6.       Have you ever had a Sexually Transmitted Disease? _____ Yes      _____ No

List the type (Chlamydia, gonorrhea, HIV, AIDS, genital herpes, Hepatitis, etc.)

            ____________________________

 

7. Answer True (T) or False (F) to the following:

   _____  Birth control prevents pregnancy

   _____  HIV is only obtained through sexual intercourse

   _____  Spermicidal lubricant is 99 percent effective in preventing sexually transmitted diseases.

   _____  One cannot transmit a sexual disease by engaging in sexual intercourse only once.

 

Demographics:

8.  What is your age? ______ years

 

9. What is your gender? _____ male     _____ female

 

10.  What is your race?   

       African-American/black_____

       White                         _____

       Hispanic/Latino           _____

       Asian American          _____

       American Indian          _____

       Alaskan native            _____

       Other                         _____

 
 

 

Space Exploration Survey

Paul Head

 

 

Thank you for taking time to complete this survey.  Your participation is completely on a voluntary basis.

This survey is entirely confidential, and your individual identity will not be made public.

 

Please indicate your level of agreement on the following items. Place a checkmark next to the number you so chose, one per item only.

 

1 = Strongly Disagree   2 = Disagree   3 = Not Sure   4 = Agree   5 = Strongly Agree

Text Box: EXAMPLE 
1. I strongly disagree with this statement.
1□   2□   3□   4□   5□ 
 

 

 

                                                                                             

 

1. Government funds should continue to be used for space exploration.

1□   2□   3□   4□   5

 

2. Funding towards space exploration has been used efficiently in the past.

1□   2□   3□   4□   5

 

3. The Space program places technological advancement ahead of celestial dreams.

1□   2□   3□   4□   5

 

4. The Space program has made great contributions to how we live today.

1□   2□   3□   4□   5

 

5. Space exploration is a government funded, independently operated, field of study.

1□   2□   3□   4□   5

 

6. Space exploration would be a justified reason to raise taxes a small percent.

1□   2□   3□   4□   5

» Explain below why you chose your answer for #6.

        _______________________________________________________________

        _______________________________________________________________

 

7. Age: ___ YEARS

 

8. Gender: Male  □ Female  □ Undisclosed

 

9. Political Party Affiliation:

            Democrat  □ Republican  □ Independent  □ Other: _____________

 

Space Exploration Survey.doc

 

Abortion Survey

Corrine Clark

This survey is designed to find out your position on the abortion issue. This survey is strictly voluntary. You are under no obligation to fill out any of it. Under no circumstances will your identity be made public on any of your responses.

Directions: Please circle ONLY ONE answer for each question unless otherwise stated.

1. Abortion should be banned regardless of any and all circumstances.

NO!    NO     no    ?    yes    YES     YES!

 

2. The reason(s) I believe the way I do about an abortion ban as indicated in question #1 is (are):

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

 

Directions: Check ONLY ONE of the following

3. When do you believe a fetus has a soul?

   __At conception    __At birth    __At some time between conception and birth

 

4. FEMALES ONLY ANSWER! (circle one)

Have you ever had an abortion?       Yes   No

If not, would you have an abortion for any reason (i.e. unwanted pregnancy, rape, etc.)?      Yes    No

 

5. MALES ONLY ANSWER! (circle one)

Have you ever encouraged and/or paid for an abortion for a spouse or significant other?       Yes     No

If not, would you encourage and/or pay for an abortion for a spouse or significant other?      Yes     No

 

6. How many abortions are performed in the U.S. each year (in raw numbers)?  __________________

 

7. What conditions, if any, must be met in order for an abortion to be illegal under federal law in the U.S.?

 

 

 

Directions: Please check all of the options that apply to your beliefs.

8. I believe that abortion is acceptable in the case(s) of:

___rape   ___incest   ___unwanted pregnancies   ___any circumstance   ___other

 

Demographic questions

1. What is your age in years? ____

2. What is your sex? Male___ Female___

 

3. Please check your race.

___European American (white)

___African American

___Native American

___Pacific Islander/Alaskan Native

___Hispanic American/Latino

___Asian American

___Other_________

 

4. Please check your political affiliation.

___Republican

___Democrat

___Other_________

___Independent/Non-Affiliated

 

5. Please check your religious affiliation.

___Roman Catholic

___Protestant

___Judaism

___Other______

___I have no religious affiliation.

Marijuana Legalization Survey

Heather Paul

 

This survey is voluntary and completely confidential. Your identity will not be made public in respect to any of the following items.

Directions: Please indicate your level of agreement on the following statement:

1-strongly agree  2- agree  3- not sure  4- disagree  5- strongly disagree

 

1.  Marijuana should be legal.  (Circle one number only)

            1   2   3   4   5  

 

2.  Why do you think marijuana should/should not be legal? Briefly explain reasons here: 

 

 

 

3. How many states have adopted varying degrees of marijuana decriminalization for cases involving personal use?

  1. 5
  2. 7
  3. 20
  4. 12

 

 4.  In recreational marijuana users, a THC blood levels will fall below 5ng/ml within how many minutes after inhalation?

  1. 60 to 90
  2. 30 to 60
  3. 15 to 30
  4. 10 to 15

 

5.  Do you smoke marijuana?  ____ Yes           ____ No

 

6.  If you answered yes to the previous question, on average, how many times do you smoke a month?

     ____________

 

7.  Do you think smoking marijuana impairs ones driving abilities?

            ____ Yes         ____ No

 

Demographics:

8.  What is your age? ____ years

 

9.  What is your gender?  ____ Female ____ Male

 

10.  What is your race?

      African-American/black  ____

      White                         ____

      Hispanic/Latino             ____

      American Indian            ____

      Alaskan native              ____

      Other                          ____

[Speech Fundamentals]

© Copyright 2001-2013.
Michael E. Eidenmuller.
The University of Texas at Tyler.
All rights reserved.