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What's your gender?
 
Male
 
Female
 
 
 
How old are you?
 
10
 
11
 
12
 
13
 
14
 
15+
 
 
 
What Race are YOU?
 
white
 
Black or African American
 
Asian
 
Native Hawaiian or other Pacific Islander
 
American Indian or Alaska Native
 
Other
 
 
 
Do you Use tobacco?
 
yes
 
No
 
 
 
Have you used tobaccoin the last month?
 
Yes
 
No
 
Maybe
 
 
 
How easey is it to get Tobacco in your community?
 
very hard
 
hard
 
not sure
 
easy
 
very easy
 
 
 
Have you ever tried to/ wanted to use tobacco products?
 
Yes
 
No
 
Don't want to answer
 
 
 
Does anyone in your house currently smoke cigarettes, or not?
 
Yes, someone does
 
No, no one does
 
Not sure
 
 
 
During the last week, how many times, if any, has someone tried to make you do something you did not want to do; for example, take or sell any tobacco products.
 
1
 
2
 
3+
 
I DON'T WANT TO ANSWER!