FAS TEEN SURVEY DATA SHEET

Directions: For each person you survey, fill out one line. For each correct answer, write a check mark in the box. Write in any incorrect answers. If they don’t know the answer, write a question mark. After you complete each survey, give the teen a Snickers bar with a Snickers FAS Card. When you have filled up this sheet, provide all information requested at the bottom, and mail this to FAS Center ATPT #7, 4710 E. 29th St., Tucson, AZ, 85711.

 Sex Grade Age #1 #2 #3 #4 #5 #6 #7 #8 #9 #10
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
 F/M     Alcohol Alcohol Alcohol Fetal Alcohol Syndrome None All Lifetime Normal All Don't Drink
Project FAS TEEN SURVEY is sponsored by a grant from the Spechard-Knight Foundation

Name of person conducting the survey: ___________________________________ Age: ________ Grade: ______
Address: __________________________________City/State___________________ Zip: ________
Phone number of person conducting survey: (___)___________ School: ___________________ Date:______________

Name of person conducting survey: ________________________________________ Age: ______ Grade: ______
Address: __________________________________City/State___________________ Zip: ________
Phone number of person conducting survey: (___)____________ School: ___________________ Date:__________

Name of sponsor: __________________________________________ Phone: (____)___________________

Mail this form along with the filled in Data Collection Sheet by March 1, 2003 (if possible) to:
FAS Center ATPT #7, 4710 E. 29th St., Tucson, AZ, 85711