Cannabis Consumers Participant Survey FormHelp us to dispel the negative stereotypes associated with people who use cannabis by filling out our survey. The information you provide may be used on our web site or in other public education materials to portray a more accurate and positive image of cannabis consumers Complete as much of this survey as possible. Don't answer the items that you don't care to or that do not apply but a valid email address is required. Your personal contact information will not be released without prior permission. Thank you. | |
| Last Name: | |
| EMail: | |
| Street: | |
| City: | |
| State: | Zip: - |
| Country: | |
| Phone: | |
| Date of birth: | / / ( MM/DD/YY : 06/18/63 = June 18, 1963 ) |
| Place of Birth: | |
| Marital Status: | |
| Do you have any children? | Yes No Ages: |
| Education: | High school Some college College grad Post grad |
| Degree(s): | Major: |
| Credentials, certifications or licenses: | |
| Occupation / vocation / special skills | |
| How do you make a living? | |
| Job Title: | |
| Do you make hiring or purchasing decisions for your company? Yes No | |
| Household Income bracket: | |
| What are your interests? E.g., Sports, music, politics, sciences, hobbies, social or cultural activities. What do you do for fun? | |
| What is your ethnic/cultural/religious affiliation? | |
| Do you give to charities? Yes No | |
| What type? | |
| Political interests? | |
| Political affiliation? | |
| Do you vote regularly? Yes No | |
| Are you active in your party? Yes No | |
| Have you received any awards or honors? Yes No | |
| Examples? | |
| Do you participate in community events or organizations? Yes No | |
| Do you volunteer? Yes No | |
| Examples? | |
| What word for "cannabis" do you most prefer? | |
| Would you prefer to state that you HAVE used or that you DO use it? | |
| When did you first use cannabis? (age/year) | |
| How frequently do you consume cannabis? Specify: | |
| Do you prefer to consume it alone, and/or with others? | |
| Describe your patterns: | |
| Please describe your personal uses/benefits from cannabis: | |
|
Stimulation
Artistic inspiration
Medicinal
Creative enhancement or inspiration
Spiritual
Relaxation/Sensory enhancement, e.g. sex, eating/music appreciation Anger management Stress reduction | |
| other: | |
| How do you consume it? Smoke Vaporize Tincture Merry pills Hash Eat | |
| other: | |
| How has cannabis impacted your health? Positively Negatively | |
| Explain: | |
| Have you used cannabis medically? Yes No | |
| For what symptom or condition? | |
| How has cannabis enhanced your life? | |
| Has cannabis had any negative effects on your life? | |
| What effects has marijuana prohibition had on you or your family? | |
| Have you turned down a job opportunity due to a drug test? Yes No | |
| Have you been discriminated against for your cannabis use? Yes No | |
| If so, how? | |
| Has cannabis affected your views on life? Yes No | |
| how so? | |
| Has cannabis affected your views on the government? Yes No | |
| how so? | |
| Does your family know about your cannabis use? Yes No | |
| How do you handle your use within your family/home? | |
| How has it affected your relationship with your kids (if any)? | |
| How out of the closet are you? Friends Co-workers Peers Completely | |
| Which high profile people have you smoked pot with? | |
| Will you refer them to join the Cannabis Consumers Campaign? Yes No | |
| Do you have any non-using friends / relatives who think cannabis should be legal for adult use? Yes No | |
| Will you refer them to our sister group, Friends and Families of Cannabis Consumers (www.equalrights4all.org)? Yes No | |
| Are you active in the current cannabis reform movement? Yes No | |
| Are you interested in becoming more active? Yes No | |
| Do you have concerns about coming out as a cannabis consumer? Yes No | |
| What are those concerns? | |
| A Statement or quote from you about cannabis: | |
| Release of liability: I hereby give permission to use my information and release Mikki Norris, Cannabis Consumers Campaign, Pot Pride, and sponsoring organizations from any liability whatsoever from any cause or reason, in con-nection with the release, dissemination and publication of statements and information that I have provided here. | |
| Take our survey and participate in the Cannabis Consumers Campaign. |