Survey Text

Survey form view entire document:  text  image

The next set of questions are about cocaine. This includes powder cocaine, crack cocaine, free base, and coca paste. Again, please answer every question -- even if you've never used cocaine. Please put an "X" in the box next to the answer that fits you best or write in your answer on the line.

79. Please put an "X" in the box next to each of the ways you have used cocaine in the past 12 months.

1[] Sniffing through the nose (snorting)
2[] Swallowing or drinking
3[] Injecting in a vein or muscle with a needle
4[] Smoking or free basing
5[] Some other way -- Specify ____
6[] I did not use cocaine in the past 12 months
8[] I HAVE NEVER used cocaine, not even once