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Please answer all questions honestly; your answers will be kept confidential.

Part A

During the PAST 12 MONTHS, did you:
1. Drink any alcohol (more than a few sips)?
2. Smoke any marijuana or hashish?
3. Use anything else to get high? “Anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”

Part B

1. Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?
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