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| Welcome to UCLA’s Medical Marijuana Research Web survey. Please be aware that this research is completely voluntary. The information obtained here will be anonymous and no individual results will be reported or disclosed to any dispensary or law enforcement. The goal of the research is to better understand whether or not the increasing numbers of dispensaries in California are related to changes in local crime and medical marijuana abuse or dependence. To thank you for taking part in this survey we will send you a $40 gift redeemable at amazon.com or its affiliates. An e-mail address will be required to send you confirmation of your e-gift. This e-mail address will remain confidential and will not be used for any other purpose but to send you the e-gift. You may end completion of this survey at any time, but the gift will only be administered to those who complete the entire survey. If you agree to participate, please click “I agree.” If not, please click “I disagree” and you will be logged out of the system. |
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| 1.What is you marital status? |
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| 2.What is the highest level of school you have completed or the highest degree you have earned? |
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| 3.How many adults live in your home? (NOTE: Because we are using a free trial I was unable to remove the text box option under the actual question.) | | | | Related adults | | | | Non-related adults | | |
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| 4.How many children? (Again, couldn't change question type with free trial) |
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| 5.What is your household income? |
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| 6.Are you a veteran of the United States Armed Services? (free trial would not allow me to add skip/branch logic) |
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| 7. Which branch of service did you serve in? |
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| 8. What era of service did you serve? |
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| 9. Are you registered with the VA hospital? |
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| 10. Do you have a service connected disability? |
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| 11. Did you deploy to combat? |
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| 12. How many times did you deploy? |
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(the free trial version would not allow my to insert a title page and instructions for "Medical Marijuana Card/Recommendation Information")
1.Where did you obtain the recommendation? |
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| 2.Who did you obtain your recommendation from? (free trial would not allow to change question type)
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| 1. On how many days in the past four weeks (28 days) did you use marijuana, hashish, edibles, beverages, honey oil, tinctures, or kief? | | |
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| 2. On the days you use marijuana, hashish, edibles, beverages, honey oil, tinctures, or keif how many different times a day do you typically use it? | | |
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| 3.In what form do you typically use marijuana? | | |
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| 4. Have you used marijuana or marijuana products today? (example of how the upload feature doesn't identify the correct question type from the word document) |
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| 1.Social services (Counseling (peer and substance-use related), men’s/women’s groups, veterans’ groups, social lounge, and other services not stated here) |
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| 2.Life Services (Housing assistance, free food, hospice delivery, referrals) |
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| 3. Entertainment (Bingo, open mic night, puzzles, poetry reading, library, Internet access, cartoons, and cereal., customer appreciation days) |
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| 4.Crafts (Quilting class, crochet class, writers’ group) |
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| 5.Cannabis related services (Legal seminars, grow classes, vaporizer lessons., edible usage, new product launches) |
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| 6.Holistic Health services (nutritional advice, massage) |
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| 7.Used an ATM or credit card at a dispensary? |
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| 1.In general, would you say your health is: |
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| 2.During the past 4 weeks, how much did your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? |
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| 3.How much bodily pain have you had during the past 4 weeks? |
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