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Does your school or neighborhood offer interesting activities for people your age to do after school?
1. No
2. Yes
Which of the following are available for people your age to do after school?
1. Organized sports
2. Scouting
3. Clubs
4. After-school programs at school
5. After-school programs outside of school
6. Classes or lessons (such as art, music, dance or drama)
7. Religious activities
8. Tutoring or mentoring
9. None of the above
10. Other activities
11. Don't know
During the past 30 days did you do any of the following things after school was over?
1. Play organized sports
2. Scouts or cubs
3. After-School Program
4. Extra classes or lessons - dance, music, etc
5. Religious activities
6. Meet a tutor
7. Hang out with friends
8. Watch TV/play on computer
9. Work at a job
10. Homework or study
11. Read
12. Talk on the phone
If your community was going to provide new activities for people your age, what would you want?
1. Organized sports and recreation
2. Arts, music, dance, and drama
3. Computer, video production, photography
4. Volunteering to help others, animals, or the environment
5. Tutors and mentors
6. Youth clubs and centers
7. Job readiness and work internships
8. Counseling
9. Alcohol and drug treatment
I feel close to people at my after-school program.
1. Strongly disagree
2. Disagree
3. Neither disagree nor agree
4. Agree
5. Strongly agree
I am happy to be at my after-school program.
1. Strongly disagree
2. Disagree
3. Neither disagree nor agree
4. Agree
5. Strongly agree
I feel like I am a part of my after-school program.
1. Strongly disagree
2. Disagree
3. Neither disagree nor agree
4. Agree
5. Strongly agree
The adults in my after-school program treat kids fairly.
1. Strongly disagree
2. Disagree
3. Neither disagree nor agree
4. Agree
5. Strongly agree
I feel safe at my after-school program.
1. Strongly disagree
2. Disagree
3. Neither disagree nor agree
4. Agree
5. Strongly agree
There is an adult at (Program), who really cares about me
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
There is an adult at (Program), who tells me when I do a good job
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
There is an adult at (Program), who notices when I'm not there
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
There is an adult at (Program), who always wants me to do my best
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
There is an adult at (Program), who listens to me when I have something to say
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
There is an adult at (Program), who believes that I will be a success
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I do interesting activities
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I help decide things like class activities or rules
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I do things that make a difference
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I do not participate in activities during non-school hours because of the cost.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I do not participate in activities during non-school hours because I do not have transportation.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
The activities that are offered after school are interesting to me.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I know of the opportunities to serve in my community.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I know how to find a volunteer opportunity in my community.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I am interested in being a volunteer.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I am a member of a youth group that has volunteered in the last six months.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
Spending time as a volunteer is important to me.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I believe volunteering helps me learn future job skills.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
During a normal week, how often do you take care of yourself after school because there are no adults around?
1. 0 times
2. One day each week
3. 2-3 days a week
4. 4-5 days a week
During a normal week, how often do you take care of yourself before school because there are no adults around?
1. 0 times
2. One day each week
3. 2-3 days a week
4. 4-5 days a week
During a normal week, how do you spend most of your after school time?
1. Playing club sports or attending TLC or Kids' Factory
2. Playing outside alone or with friends
3. Doing homework
4. Riding a scooter, rollerblading, or skateboarding
5. Watching TV,or playing video or computer games
6. Attending music, dance or art lessons
7. Surfing the internet for fun
Does your parent...Ever help or volunteer in your classroom
1. No
2. Yes
Does your parent...Come to school activities
1. No
2. Yes
Does your parent...Check your homework
1. No
2. Yes
Does your parent...Read with you at home
1. No
2. Yes
Does your parent...Talk with you about your goals for the future
1. No
2. Yes
Does your parent...Talk with you about your problems
1. No
2. Yes
Has your parent visited your school this year?
1. No
2. Yes
Has your parent ever met your teacher?
1. No
2. Yes
Has your teacher ever visited your house?
1. No
2. Yes
Have you ever taken part in a support group?
1. No
2. Yes
Have you ever received any type of school counseling?
1. No
2. Yes
How many times in the past 30 days have you been absent from school for even one period?
1. 0 times
2. 1 time
3. 2-5 times
4. 6-10 times
5. 11 or more times
Have you ever felt that you needed help (such as counseling or treatment) for your alcohol or other drug use?
1. I have never used alcohol or other drugs
2. No, but I do use alcohol or other drugs
3. Yes, I have felt that I needed help
4. Don't know
During the past 12 months, did you ever seriously consider attempting suicide?
1. No
2. Yes
During the past 12 months, did you make a plan about how you would attempt suicide?
1. No
2. Yes
During the past 12 months, how many times did you actually attempt suicide?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?
1. No
2. Yes
During the last 4 weeks, how many days of school have you missed because you skipped or ÒditchedÓ?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
Past 12 months, did you ever seriously consider attempting suicide?
1. No
2. Yes
Past 12 months, did you make a plan about how you would attempt suicide?
1. No
2. Yes
Past 12 months, how many times did you actually attempt suicide?
1. 0 times
2. 1 time
3. 2-3 times
4. 4 or more times
Past 12 months, if you attempted suicide, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?
1. I did not attempt suicide in the past 12 months
2. No
3. Yes
Past 12 months, did you ever think about killing yourself?
1. No
2. Yes
Past 12 months, did you make a plan about how you would like to kill yourself?
1. No
2. Yes
Have you ever tried to kill yourself?
1. No
2. Yes
Stress/Depression, would most likely talk to or get advice/information?
1. Friend
2. Brother/Sister
3. Parent/Guardian
4. Teacher/Counselor
5. Other Adult
6. Internet
7. Hotline/Agency
8. Other
Have you ever called a hotline for help with problems you are having at school, home or elsewhere?
1. Yes
2. No
Have you ever been or are you currently part of any of the following?
1. Boys Republic or Buena Vista
2. Alternatives to expulsion
3. Pregnant minor/parenting teen
4. School within a school (SWAS)
5. Family and/or peer group using addictive substances
6. Often spend time at or near known smoking areas in school
7. Male athlete
8. Suspended from school 2 or more times
I like to come to school each day.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
School is important for success in life.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
My school is preparing me well to succeed in college.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
The lessons in school are interesting to me.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
Do you know where to go in your community to get advice on personal problems?
1. No
2. Yes
If you needed advice on personal problems, to whom or where would you go first?
1. Counselor
2. Doctor/Nurse
3. Friend
I feel successful in school.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I feel comfortable talking with others who are different from me.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I feel included by other students at my school.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I am part of more than one group at school.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I help make my school a caring place.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I have done community service within the past year.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
Doing community service is rewarding to me.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
Students at my school treat each other with respect.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
Students at my school treat teachers with respect.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
My school is a caring place
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
My school offers opportunities to work with people who are different from me.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
During the past 12 months, how many times have your been a leader in a school, community, or church group or organization?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
In my school, there are clear rules about what students can and cannot do.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
In my family, there are clear rules about what I can and cannot do.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
My teachers really care about me.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
On the whole, I like myself.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
Have you learned, in school, techniques or skills for making decisions and coping with your choices?
1. No
2. Yes
If you have learned these techniques/skills, how often do you use them in your daily life?
1. Have not used them yet
2. Rarely use them
3. Occasionally use them
4. Frequently use them
Have you ever had a mentor?
1. Yes
2. No
3. I'm not sure
4. I don't know what a mentor is
If yes, did having a mentor help you?
1. Yes
2. No
3. I'm not sure
If you haven't had a mentor, would you like one now?
1. Yes
2. No
3. I'm not sure what a mentor is
Can you identify one adult on this campus that you believe cares for you?
1. Yes
2. No
3. I'm not sure
Do you feel that there is at least one adult on campus that you can talk to?
1. Yes
2. No
3. I'm not sure
Have you found a good friend in another student at (school/program)?
1. Yes I have made many friends
2. Yes I have a small group of friends
3. Yes I have a good friend
4. No I have found it difficult to make friends
5. No I don't have any friends
6. It's too soon to tell
I know where to go for help with a problem.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I have goals and plans for the future.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I plan to graduate from high school.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I plan to go to college or some other school after high school.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
I know an adult I can talk to when I have problem at school.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
I know how to deal with peer pressure.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
What is the #1 hardest thing to deal with for people your age?
1. Peer pressure
2. Drugs/Alcohol
3. Violence/Gangs
4. Stress/Depression
5. Getting along with students/making friends
6. Dating/Relationships
7. Boredom
8. Other problem
Have you ever been suspended from high school?
1. Yes
2. No
3. Don't remember
Have you ever run away from home?
1. Yes
2. No
3. Don't remember
In your neighborhood, have gang members done the following? Gotten into fights, provided protection for each other, Stolen things, Damaged property, Sold drugs, Carried weapons.
1. Often
2. Sometimes
3. Never
4. Don't know
If you wanted to get a gun (such as a handgun, rifle, or shotgun), how easy would it be for you to get one?
1. Very hard
2. Fairly hard
3. Fairly easy
4. Very easy
5. Don't know
Are there adults you feel close to who...use illegal drugs, are gang members, have gotten into trouble with police, sell or deal drugs, would approve of you hanging out with gang members, would approve of you becoming a gang member?
1. None
2. Some
3. Many
4. Most or all
5. Don't know
Are there gang members at your school?
1. A lot
2. Some
3. Few
4. None
5. Don't know
Are there gang members in your neighborhood?
1. A lot
2. Some
3. Few
4. None
5. Don't know
How many of your friends are in a gang?
1. A lot
2. Some
3. Few
4. None
At your school, have gang members done the following? Gotten into fights, provided protection for each other, Stolen things, Damaged property, Sold drugs, Carried weapons.
1. Often
2. Sometimes
3. Never
4. Don't know
Have you ever been a member of a gang?
1. No
2. Yes
How old were you when you first joined a gang?
1. 10 years old or younger
2. 11 years old
3. 12 years old
4. 13 years old
5. 14 years old
6. 15 years old
7. 16 years old
8. 17 years old or older
Why did you join this gang?
1. For fun
2. For protection
3. A friend was in the gang
4. A relative was in the gang
5. I was forced to join
6. To get respect
7. For money
8. To fit in better
9. Other reason(s)
Does this gang have the following characteristics?
1. Members younger than age 13
2. Initiation rites
3. A name
4. Leaders
5. Regular meetings
6. Rules or codes
7. Members with specific roles
8. Symbols or colors
How many members are there in this gang?
1. 1-5
2. 6-10
3. 11-20
4. 21-30
5. More than 30
If you once considered yourself a member of a gang but do not now, why did you leave the gang?
1. Does not apply; I still consider myself a member of a gang
2. Moved where there were no gangs
3. Changed schools
4. Parents did not approve
5. Religious belief
6. Got into too much trouble
7. Got hurt or someone I knew got hurt
8. Other
I have safe places to go to participate in activities during non-school hours.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I have safe places to go to participate in activities when school is not in session.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I need more information about safe places to go during non-school hours.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
Have you ever been teased by other kids at school?
1. No
2. Yes
Have you ever teased other kids at school?
1. No
2. Yes
If you saw another student being bullied, what would you do?
1. Tell an adult at school
2. Laugh or join in
3. Nothing
Adults at my school know when kids are being bullied?
1. No
2. Yes
If you saw a kid being pushed or hit by another student, what would you do?
1. Tell an adult at school
2. Laugh or join in
3. Nothing
4. Tell the other kids to stop bullying the student
If you got into an argument with a friend, what would you do?
1. Tell your friend you are sorry
2. Start a physical fight with your friend
3. Spread a rumor about your friend
4. Ignore your friend until they told you sorry
If somebody in your class makes you angry, would you still be their friend?
1. No, never
2. Maybe
3. Yes, but I would tell them to stop making me angry
4. Yes, my friends always make me angry
Have rumors ever been spread about you?
1. No
2. Yes
Have you ever spread rumors?
1. No
2. Yes
Have anyone at school ever threatened you?
1. No
2. Yes
Have you ever threatened anyone at school?
1. No
2. Yes
Do you ever feel left out by your friends?
1. No
2. Yes
Do you wish you had more friends?
1. No - I have a lot of friends
2. Yes - maybe one or two more
3. Yes - I do not have any friends
4. Yes - I do not like the friend I have
Is there an adult at your school who you feel you can trust?
1. No
2. Yes
I would welcome having police on my school campus
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
Police provide valuable services in addition to apprehending people who have committed crimes.
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
Police can generally be trusted to treat people fairly.
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
The canine-assisted searches for drugs at school should be continued.
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
Is it okay to say something mean to a student who is pushing you around?
1. No
2. Yes
It is ok to hit someone who has hit you first?
1. No
2. Yes
If someone threatens or harasses me, I know where to go for help.
1. No
2. Yes
When students ask for help they are taken seriously.
1. No
2. Yes
I know where to go to report acts of violence, aggression, or harassment.
1. No
2. Yes
Talk to another friend about it, would do if a friend was in an abusive relationship.
1. I definitely would
2. I probably would
3. I'm not sure
4. I probably wouldn't
5. I definitely wouldn't
Talk to an adult at school about it, would do if a friend was in an abusive relationship.
1. I definitely would
2. I probably would
3. I'm not sure
4. I probably wouldn't
5. I definitely wouldn't
Talk to parents or other adult away from school about it, would do if a friend was in an abusive relationship.
1. I definitely would
2. I probably would
3. I'm not sure
4. I probably wouldn't
5. I definitely wouldn't
Stay out of it, would do if a friend was in an abusive relationship.
1. I definitely would
2. I probably would
3. I'm not sure
4. I probably wouldn't
5. I definitely wouldn't
Talk to another friend about it, would do if a friend was having major problems at home.
1. I definitely would
2. I probably would
3. I'm not sure
4. I probably wouldn't
5. I definitely wouldn't
Talk to an adult at school about it, would do if a friend was having major problems at home.
1. I definitely would
2. I probably would
3. I'm not sure
4. I probably wouldn't
5. I definitely wouldn't
Talk to parents or other adult away from school about it, would do if a friend was having major problems at home.
1. I definitely would
2. I probably would
3. I'm not sure
4. I probably wouldn't
5. I definitely wouldn't
Stay out of it, would do if a friend was having major problems at home.
1. I definitely would
2. I probably would
3. I'm not sure
4. I probably wouldn't
5. I definitely wouldn't
Past 12 months, Been pushed, shoved, slapped, hit or kicked, by someone who wasnÕt just kidding around at school?
1. None
2. Once
3. Twice
4. Three times or more
Past 12 months, Been afraid of being beaten up at school?
1. None
2. Once
3. Twice
4. Three times or more
Past 12 months, Had mean rumors or lies spread about you at school?
1. None
2. Once
3. Twice
4. Three times or more
Past 12 months, Had sexual jokes, comments, or gestures made to you at school?
1. None
2. Once
3. Twice
4. Three times or more
Past 12 months, Been made fun of because of your looks or the way you talk at school?
1. None
2. Once
3. Twice
4. Three times or more
Past 12 months, harassed or bullied because of your race, ethnicity, or national origin on school property?
1. None
2. Once
3. Twice
4. Three times or more
Past 12 months, harassed or bullied because of your gender on school property?
1. None
2. Once
3. Twice
4. Three times or more
Past 12 months, harassed or bullied because of you are gay or lesbian or someone thought you were on school property?
1. None
2. Once
3. Twice
4. Three times or more
Past 12 months, harassed or bullied because of a physical/mental disability or other reason on school property?
1. None
2. Once
3. Twice
4. Three times or more
Problems with other students, would most likely talk to or get advice/information?
1. Friend
2. Brother/Sister
3. Parent/Guardian
4. Teacher/Counselor
5. Other Adult
6. Internet
7. Hotline/Agency
8. Other
How safe do you feel in the neighborhood where you live?
1. Very safe
2. Safe
3. Neither safe nor unsafe
4. Unsafe
5. Very unsafe
Past 30 days, did not go to school because of feeling unsafe on the way to, at, or coming home from school?
1. 0 days
2. 1 day
3. 2 or 3 days
4. 4 or more days
During the past 12 months, how many times have you... Been physically hurt or threatened going to or from school, Sold drugs to someone, Been in a physical fight between groups of kids, Used a weapon to threaten or bully someone, Stole or tried to steal
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
During the past 12 months how many times have you...Been in a physical fight in which you were injured?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
During the past 12 months how many times have you...Been in a physical fight between groups of kids?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
During the past 12 months how many times have you...Used a weapon (gun, knife, or club) to threaten or bully someone?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
During the past 12 months how many times have you...Been arrested (by police or sheriff)?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
During the past 30 days months how many days did you carry...A weapon such as a knife, or club?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
During the past 30 days months how many days did you carry...A gun?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
If you wanted to get a gun, how difficult would it be to get one?
1. Very hard
2. Fairly hard
3. Fairly easy
4. Very easy
5. Don't know
How safe do you feel when you walk to and from school?
1. Very safe
2. Neither safe nor unsafe
3. Unsafe
4. Very unsafe
Violence/Gang Activity, would most likely talk to or get advice/information?
1. Friend
2. Brother/Sister
3. Parent/Guardian
4. Teacher/Counselor
5. Other Adult
6. Internet
7. Hotline/Agency
8. Other
Have you ever been arrested?
1. Yes
2. No
3. Don't remember
Have you ever received a warning or citation from the police?
1. Yes
2. No
3. Don't remember
HIV/AIDS is a harmful effect of tobacco use?
1. Yes
2. No
How old were you when you first used tobacco?
1. Never used
2. 7 or younger
3. 8-13
4. 14-15
5. 16+
How many of your best friends smoke cigarettes?
1. None
2. A few
3. Several
4. Most
5. All or nearly all
How would your parent(s) feel if you smoked or used any tobacco products?
1. Feel it was fine
2. No feeling about it
3. Feel it was wrong
How would your brother(s)/sister(s) feel if you smoked or used any tobacco products?
1. Feel it was fine
2. No feeling about it
3. Feel it was wrong
How would you feel about your parent(s) smoking cigarettes?
1. Feel it was fine
2. No feeling about it
3. Feel it was wrong
How would you feel about your brother(s)/sister(s) smoking cigarettes?
1. Feel it was fine
2. No feeling about it
3. Feel it was wrong
How would you feel about your close friend(s) smoking cigarettes?
1. Feel it was fine
2. No feeling about it
3. Feel it was wrong
In your home, does someone smoke?
1. No
2. Yes one parent smokes
3. Yes both parents smoke
Cigarette advertisements make young people want to start smoking, agree?
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
5. Don't know
Smoking is a good way to keep your weight down, agree?
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
5. Don't know
Breathing second hand smoke is bad for your health, agree?
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
5. Don't know
Teens are too young to get addicted to tobacco, agree?
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
5. Don't know
Smokers have less energy than non-smokers, agree?
1. Very much agree
2. Agree
3. Disagree
4. Very much disagree
5. Don't know
Why do most kids your age use tobacco?
1. Curious to see what it is like
2. Because their friends use it
3. It is part of having fun
4. Bored nothing else to do
5. Because they need it
6. Keeps weight down
7. It relaxes them
8. It is a way to appear older
9. It is a way to rebel
How harmful do you think it is to smoke cigarettes frequently (1 every day)?
1. Extremely harmful
2. Somewhat harmful
3. Not too harmful
4. Not harmful at all
How harmful do you think it is to smoke cigarettes occasionally (once in a while)?
1. Extremely harmful
2. Somewhat harmful
3. Not too harmful
4. Not harmful at all
Were you aware of the following occuring during the past 12 months?
1. Student newsletter coverage on tobacco-related issues
2. Increased local news media coverage on tobacco-related issues
3. Anti-tobacco public service announcements by stuents
4. More posters/info about tobacco issues on campus
5. Student advocates on campus promoting no tobacco use
Past year, did your school celebrate special days such as 'Great American Smoke-out, Save a Sweet Heart', or 'Kick Butts Day'?
1. No
2. Yes
3. I don't know I'm not sure
Past year, was the information you received in school helpful in making decisions about tobacco use?
1. Yes very helpful
2. Yes sort of helpful
3. Have not received any information
4. No not very helpful
5. No not helpful at all
Does your school have any special groups or classes for students who want to quit using tobacco?
1. No
2. Yes
3. I don't know I'm not sure
Are there teachers or adults at your school that you could talk to if you had a tobacco use problem?
1. No
2. Yes
3. I don't know I'm not sure
Do you have friends who smoke cigarettes?
1. No
2. Yes
Would you rather have friends who don't smoke cigarettes?
1. No
2. Yes
3. It doesn't matter to me
At what age did you first try smoking a cigarette?
1. I've never tried it
2. 2-5 years old
3. 6-8 years old
4. 9-10 years old
5. 11-12 years old
6. 13 years old
7. 14 years old
8. 15 years old
9. 16 years old
10. 17 years old or older
Do you have friends who use smokeless tobacco?
1. Yes
2. No
Would you rather have friends who don't use smokeless tobacco?
1. No
2. Yes
3. It doesn't matter to me
At what age did you first try smokeless tobacco?
1. I've never tried it
2. 2-5 years old
3. 6-8 years old
4. 9-10 years old
5. 11-12 years old
6. 13 years old
7. 14 years old
8. 15 years old
9. 16 years old
10. 17 years old or older
How difficult is it for students in your grade level to get smokeless tobacco?
1. Very difficult
2. Fairly difficult
3. Fairly easy
4. Very easy
5. I donÕt know
How harmful do you think it is to use smokeless tobacco daily or almost daily?
1. Extremely harmful
2. Harmful
3. Somewhat Harmful
4. Mainly Harmless
5. Harmless
Where do students at your school who use smokeless tobacco most often get it?
1. I donÕt know
2. Friends
3. Parties
4. At home
5. Other family members not living at home
6. Stores
7. Vending Machines
8. Other
Influenza is a harmful effect of tobacco use?
1. Yes
2. No
Cancer is a harmful effect of tobacco use?
1. Yes
2. No
Low birth-weight babies is a harmful effect of tobacco use?
1. Yes
2. No
Tuberculosis is a harmful effect of tobacco use?
1. Yes
2. No
Pediculosis is a harmful effect of tobacco use?
1. Yes
2. No
Heart disease is a harmful effect of tobacco use?
1. Yes
2. No
Emphysema is a harmful effect of tobacco use?
1. Yes
2. No
How wrong do your parents feel it would be for you to smoke cigarettes?
1. Very wrong
2. Wrong
3. A little bit wrong
4. Not at all wrong
How old were you the first time you smoked a cigarette, even just a puff?
1. Never
2. 10 years or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
Past year, how often have your friends pressured you to use tobacco?
1. Never
2. Once or twice
3. 3 or more times
Have you ever refused tobacco from a friend or acquaintance?
1. No
2. Yes
If yes, how many times have you refused tobacco?
1. Once
2. Two to three times
3. Four to six times
4. Seven to ten times
5. Ten or more times
Past 12 months, talked calmly with parents/guardians about dangers of tobacco use?
1. No
2. Yes
How do you think your parents/guardians would feel about you smoking cigarettes?
1. Would strongly disapprove
2. Would somewhat disapprove
3. Would not disapprove
How do you think your close friends would feel about you smoking cigarettes?
1. Would strongly disapprove
2. Would somewhat disapprove
3. Would not disapprove
How old were you the first time you used any type of tobacco product?
1. Never
2. 10 years old or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
10. 18 years old
How much would your parents/guardians disapprove of you using tobacco?
1. A lot
2. Some
3. Not much
4. Not at all
Last school year, on how many days did you have a lesson on tobacco in any of your classes?
1. None
2. 1 or 2
3. 3 to 5
4. More than 5
How often are you around others who use tobacco?
1. Very often
2. Often
3. Sometimes
4. Not very often
5. Never
How likely is it that a student would find help at your school to stop using cigarettes?
1. Not likely
2. Somewhat likely
3. Very likely
Did you ever go through the County Little Bus of Tobacco Horrors (the Tobacco Bus)?
1. No
2. Yes
3. Don't know
Has using alcohol, marijuana, or other drugs ever caused you to: (choose only one)
1. Get into trouble or have problems with the police
2. Get into trouble in school or miss school
3. Have problems with school work
4. Fight with other kids
5. Damage/lose a friendship
6. Have any other problems
7. Have used, but never had a problem
8. Does not apply, have never used
Has using alcohol, marijuana, or other drugs ever resulted in you: (choose only one)
1. Physically hurting or injuring yourself
2. Having unwanted sex
3. Having unprotected sex
4. Forgetting what happened passing out or losing control
5. Having other problems
6. Have used but never had a problem
7. Does not apply have never used
During the past 12 months, on how many days did you have a lesson on tobacco, alcohol, and other drugs in school?
1. None
2. 1 to 4 days
3. 5 to 9 days
4. 10 to 14 days
5. 15 or more days
Have you ever experienced a presentation at school by a Peer Educator about Tobacco?
1. No
2. Yes
Past 12 months, had a separate course on alcohol/drugs at school?
1. Yes
2. No
3. Not sure
Past 12 months, received information as part of another course, such as health ed, life skills, or science at school?
1. Yes
2. No
3. Not sure
Past 12 months, attended assemblies or other one time events on alcohol/drug abuse at school?
1. Yes
2. No
3. Not sure
Past 12 months, participate in student prevention activities, such as Club Live, Friday Night Live, or support groups at school?
1. Yes
2. No
3. Not sure
Past 12 months, did you receive information on alcohol, tobacco or drugs in a class such as health, science or PE?
1. No
2. Yes
3. Not sure
Past 12 months, did you participate in clubs or prevention activities that promote ATOD-free lifestyles?
1. No
2. Yes
3. Not sure
Past 12 months, did you participate in a support group at school or in the community that addressed ATOD use?
1. No
2. Yes
3. Not sure
Past 12 months, Take part in mediation session/training in how to resolve conflict/reduce violence/prevent bullying?
1. No
2. Yes
3. Not sure
Past 12 months, did you participate in a sober or drug-free event?
1. No
2. Yes
3. Not sure
Past 12 months, did you participate in activities that promote respect and understanding for others?
1. No
2. Yes
I was offered drugs or alcohol during the past year
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
How do most kids at your school who drink alcohol usually get it?
1. At school
2. Activities outside school
3. At their own home
4. From adults
5. At friends' homes
6. From friends or another kid
7. Get adults to buy it for them
8. Buy it themselves from a store
If you drink alcohol, what type do you most often drink?
1. I don't drink alcohol
2. Beer
3. Hard liquor
4. Wine or wine coolers
5. 'Alco-pops'
6. Other
How old were you when you smoked a whole cigarette for the first time?
1. I have never smoked a whole cigarette
2. 8 yrs old or younger
3. 9-10 yrs
4. 11-12 yrs
5. 13-14 yrs
6. 15-16 yrs
7. 17 yrs or older
How old were you when you had your first drink of alcohol other than a few sips?
1. I have never had a drink of alcohol other than a few sips
2. 8 yrs old or younger
3. 9-10 yrs
4. 11-12 yrs
5. 13-14 yrs
6. 15-16 yrs
7. 17 yrs or older
How old were you when you tried marijuana for the first time?
1. I have never tried marijuana
2. 8 yrs old or younger
3. 9-10 yrs
4. 11-12 yrs
5. 13-14 yrs
6. 15-16 yrs
7. 17 yrs or older
During the past 12 months how many times have you...Sold drugs to someone?
1. 0 times
2. 1 time
3. 2 to 3 times
4. 4 or more times
Where do most kids at your school, who use drugs, get them?
1. At school
2. At parties or events outside of school
3. At home
4. In the neighborhood
5. DonÕt know
How much would your parents disapprove of you for using...Alcohol
1. Strongly disapprove
2. Disapprove
3. Neither disapprove nor approve
4. Approve
5. Strongly approve
How much would your parents disapprove of you for using...Marijuana
1. Strongly disapprove
2. Disapprove
3. Neither disapprove nor approve
4. Approve
5. Strongly approve
How much would your parents disapprove of you for using...Tobacco
1. Strongly disapprove
2. Disapprove
3. Neither disapprove nor approve
4. Approve
5. Strongly approve
How much would your parents disapprove of you for using...Inhalants
1. Strongly disapprove
2. Disapprove
3. Neither disapprove nor approve
4. Approve
5. Strongly approve
How much would your parents disapprove of you for using...Ecstasy
1. Strongly disapprove
2. Disapprove
3. Neither disapprove nor approve
4. Approve
5. Strongly approve
How much would your parents disapprove of you for using...Methamphetamine (meth)
1. Strongly disapprove
2. Disapprove
3. Neither disapprove nor approve
4. Approve
5. Strongly approve
How much would your parents disapprove of you for using...Other illegal drugs
1. Strongly disapprove
2. Disapprove
3. Neither disapprove nor approve
4. Approve
5. Strongly approve
About how old were you the first time you did any of these things? Inhalants
1. Never used
2. 7 or younger
3. 8-13
4. 14-15
5. 16+
About how old were you the first time you did any of these things? Ecstasy
1. Never used
2. 7 or younger
3. 8-13
4. 14-15
5. 16+
About how old were you the first time you did any of these things? Meth
1. Never used
2. 7 or younger
3. 8-13
4. 14-15
5. 16+
How do you get alcohol?
1. At school
2. At parties or events outside of school
3. At home
4. Friends or another youth
5. Get adults to buy for you
6. Buy it yourself at a store
7. Other
8. I don't drink alcohol
Past 30 days, how many days did you use smokeless tobacco?
1. 1 dip a day
2. 2 to 5 dips a day
3. 6 to 10 dips a day
4. More than 10 dips a day
5. Did not use smokeless tobacco in the past 30 days
Past 12 months, where have you used alcohol the most?
1. At home
2. At school
3. At a party
4. At a sporting event
5. At a friend's house
6. By yourself
7. Does not apply never used alcohol
Past 30 days, how many times did you drink an alcopop beverage?
1. 0 times
2. 1 time
3. 2-3 times
4. 4 or more times
Past 30 days, how often have you seen alcopops advertising?
1. 0 times
2. 1 time
3. 2-3 times
4. 4 or more times
Alcopops taste better than beer or other drinks that contain alcohol
1. Strongly disagree
2. Somewhat disagree
3. Don't agree or disagree
4. Somewhat agree
5. Strongly agree
6. Don't know
You can't get as drunk drinking alcopops compared to other forms of alcohol?
1. Strongly disagree
2. Somewhat disagree
3. Don't agree or disagree
4. Somewhat agree
5. Strongly agree
6. Don't know
Girls drink alcopops more than guys.
1. Strongly disagree
2. Somewhat disagree
3. Don't agree or disagree
4. Somewhat agree
5. Strongly agree
6. Don't know
Alcopops advertisements target adults more than youth.
1. Strongly disagree
2. Somewhat disagree
3. Don't agree or disagree
4. Somewhat agree
5. Strongly agree
6. Don't know
Alcopops are easy to get.
1. Strongly disagree
2. Somewhat disagree
3. Don't agree or disagree
4. Somewhat agree
5. Strongly agree
6. Don't know
Advertising for alcopops are cool because they use good-looking girls and guys.
1. Strongly disagree
2. Somewhat disagree
3. Don't agree or disagree
4. Somewhat agree
5. Strongly agree
6. Don't know
How old were you the first time you tried any drug, not alcohol, such as marijuana, inhalants, or other?
1. Never
2. 10 years or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
10. 18 years old or older
How old were you the first time you bet or gambled for money at a casino, card room, lottery, or over the internet?
1. Never
2. 10 years or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
10. 18 years old or older
How wrong do your parents feel it would be for you to drink beer, wine, or hard liquor regularly (at least once a month)?
1. Very wrong
2. Wrong
3. A little bit wrong
4. Not at all wrong
How wrong do your parents feel it would be for you to smoke marijuana?
1. Very wrong
2. Wrong
3. A little bit wrong
4. Not at all wrong
How wrong do your parents feel it would be for you to use over-the-counter medications or prescription drugs without a doctor's prescription or parental supervision?
1. Very wrong
2. Wrong
3. A little bit wrong
4. Not at all wrong
How old were you the first time you smoked marijuana?
1. Never
2. 10 years or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
How old were you the first time you had more than a sip or two of beer, wine, or hard liquor?
1. Never
2. 10 years or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
How old were you when you first began drinking alcoholic beverages regularly (at least once a month)?
1. Never
2. 10 years or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
How old were you when you began using over-the-counter medications or prescription drugs without a doctor's prescription or parental supervision?
1. Never
2. 10 years or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
Past year, have you had even one drink of alcohol?
1. Never
2. Once or twice
3. 3 or more times
Bought alcohol from gas station, liquor store, mini-mart, or grocery store?
1. Never
2. Once or twice
3. 3 or more times
Got alcohol from adult outside of family who bought it for me?
1. Never
2. Once or twice
3. 3 or more times
Got alcohol at parties and social events where parents were not present?
1. Never
2. Once or twice
3. 3 or more times
Got alcohol at parties and social events where parents were present?
1. Never
2. Once or twice
3. 3 or more times
Got alcohol from a friend's home?
1. Never
2. Once or twice
3. 3 or more times
Got alcohol from a family member?
1. Never
2. Once or twice
3. 3 or more times
Got alcohol from my house without my parents' permission?
1. Never
2. Once or twice
3. 3 or more times
Past year, drank alcohol at parties?
1. Never
2. Once or twice
3. 3 or more times
Past year, drank alcohol at a friend's home?
1. Never
2. Once or twice
3. 3 or more times
Past year, drank alcohol at my house?
1. Never
2. Once or twice
3. 3 or more times
Past year, drank alcohol while hanging out in cars, in parking lots, or out in the fields?
1. Never
2. Once or twice
3. 3 or more times
Past year, drank alcohol at family events?
1. Never
2. Once or twice
3. 3 or more times
Past year, drank alcohol at school?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have you used steroids?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have you used ecstasy?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have you lied to an adult so you could use alcohol?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have you lied to an adult so you could use drugs?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have your friends pressured you to drink alcohol?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have your friends pressured you to use marijuana?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have your friends pressured you to use steroids?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have your friends pressured you to use ecstasy or other club drugs?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have your friends pressured you to use methamphetamines?
1. Never
2. Once or twice
3. 3 or more times
Past year, how often have your friends pressured you to use other illegal drugs?
1. Never
2. Once or twice
3. 3 or more times
Past 12 months, did you receive any information or education about using alcohol or other drugs in any of your classes?
1. No
2. Yes
3. Don't know
How has what you learned in school about alcohol or other drugs affected you?
1. Never had classes or programs on AOD in school
2. Learned to avoid use of alcohol
3. Learned to avoid use of drugs
4. Helped me resist pressure from my friends to use AOD
5. Learned how AOD can be harmful to my health
6. Helped me to understand and deal with my feelings
7. Helped me seek help for my AOD use
8. Helped me talk with my parents about my AOD use
9. Has not affected or taught me anything
10. Had already decided on my own not to use AOD
11. Made me more interested in trying AOD
Did you find the information particularly interesting because it was given by a Peer Educator rather than an adult?
1. No
2. Yes
How old were you the first time you felt high, drunk, intoxicated from any kind of alcoholic beverage?
1. Never used
2. 11 years or under
3. 12-13 years
4. 14-15 years
5. 16+ years
How old were you the first time you felt high or loaded from any kind of drug?
1. Never used
2. 11 years or under
3. 12-13 years
4. 14-15 years
5. 16+ years
Learned to avoid or reduce use of alcohol because of what you've learned in school about AOD?
1. Yes
2. No
3. Not sure
Learned to avoid or reduce use of drugs because of what you've learned in school about AOD?
1. Yes
2. No
3. Not sure
Has what you have learned in school about AOD helped you resist pressure from your friends to use drugs and alcohol?
1. Yes
2. No
3. Not sure
Learned how alcohol and other drugs can be harmful to your health because of what you've learned in school about AOD?
1. Yes
2. No
3. Not sure
Has what you have learned in school about AOD helped you understand and deal with your feelings?
1. Yes
2. No
3. Not sure
Has what you have learned in school about AOD helped you seek treatment or counseling for your alcohol or drug use?
1. Yes
2. No
3. Not sure
Has what you have learned in school about AOD helped you talk to your parents about your alcohol or drug use?
1. Yes
2. No
3. Not sure
Has what you have learned in school about AOD not affected or taught you anything?
1. Yes
2. No
3. Not sure
Has what you have learned in school about AOD made you more interested in trying drugs?
1. Yes
2. No
3. Not sure
Had you already decided on your own not to use drugs or drink alcohol?
1. Yes
2. No
3. Not sure
Past 12 months, talked calmly with parents/guardians about dangers of alcohol use?
1. No
2. Yes
Past 12 months, talked calmly with parents/guardians about dangers of marijuana use?
1. No
2. Yes
How do you think your parents/guardians would feel about you drinking alcohol?
1. Would strongly disapprove
2. Would somewhat disapprove
3. Would not disapprove
How do you think your close friends would feel about you drinking alcohol?
1. Would strongly disapprove
2. Would somewhat disapprove
3. Would not disapprove
How do you think your parents/guardians would feel about you using marijuana?
1. Would strongly disapprove
2. Would somewhat disapprove
3. Would not disapprove
How do you think your close friends would feel about you using marijuana?
1. Would strongly disapprove
2. Would somewhat disapprove
3. Would not disapprove
Learned to avoid or reduce use of alcohol, tobacco, or drugs because of activities in questions G10-G15?
1. No
2. Yes
Helped me resist pressure from my friends to use ATOD because of activities in questions G10-G15?
1. No
2. Yes
Learned how alcohol, tobacco, or drugs can be harmful to my health because of activities in questions G10-G15?
1. No
2. Yes
Helped me learn respect/tolerance and/or avoid/reduce violence/fighting/bullying because of activities in G10-G15?
1. No
2. Yes
Helped me talk with my parents about my alcohol or drug use because of activities in questions G10-G15?
1. No
2. Yes
Past 12 months, obtained alcohol from your home?
1. No
2. Yes
Past 12 months, obtained alcohol from a friend's home?
1. No
2. Yes
Past 12 months, obtained alcohol at parties or social events where parents WERE present?
1. No
2. Yes
Past 12 months, obtained alcohol at parties or social events where parents WERE NOT present?
1. No
2. Yes
Past 12 months, got alcohol purchased by stranger/older friend/relative from gas station or convenience/liquor/grocery?
1. No
2. Yes
Past 12 months, obtained alcohol yourself from a gas station, convenience store, liquor store, or grocery store?
1. No
2. Yes
Past 12 months, did you drink alcohol at family events at least once?
1. No
2. Yes
Past 12 months did you drink alcohol when by yourself at least once?
1. No
2. Yes
Past 12 months, did you drink alcohol with others while hanging out at parks, playgrounds, beaches, or vacant lots?
1. No
2. Yes
Past 12 months, did you drink alcohol with others in a limousine?
1. No
2. Yes
Past 12 months, did you drink alcohol while hanging out in cars or at parking lots?
1. No
2. Yes
Past 12 months, did you drink alcohol or use drugs with others in a motel room?
1. No
2. Yes
Past 12 months, did you use a fake ID?
1. No
2. Yes
Past 12 months, did you use steroids to become stronger or more muscular?
1. No
2. Yes
How old were you the first time you felt high, drunk, or intoxicated from any kind of alcoholic drink?
1. Never
2. 10 years old or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
10. 18 years old
How old were you the first time you felt high or loaded from marijuana?
1. Never
2. 10 years old or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
10. 18 years old
How old were you the first time you felt high or loaded from any other kind of drug?
1. Never
2. 10 years old or younger
3. 11 years old
4. 12 years old
5. 13 years old
6. 14 years old
7. 15 years old
8. 16 years old
9. 17 years old
10. 18 years old
Past 12 months, have you misused prescription pain medications or pain killers?
1. No
2. Yes
Past 12 months, have you misused prescription anti-depressants or tranquilizers?
1. No
2. Yes
Past 12 months, have you misused prescription stimulants for ADHD?
1. No
2. Yes
Past 12 months, have you misused over-the-counter antihistamines?
1. No
2. Yes
Past 12 months, have you misused over the counter cold or cough medication?
1. No
2. Yes
During the past 12 months, have you used any high-caffeine/keep alert products to get high or loaded?
1. No
2. Yes
How much would your parents/guardians disapprove of you using alcohol?
1. A lot
2. Some
3. Not much
4. Not at all
How much would your parents/guardians disapprove of you using marijuana?
1. A lot
2. Some
3. Not much
4. Not at all
Past 12 months, did you use steroid pills or shots without a doctor's orders?
1. No
2. Yes
Past 12 months, have you used anti-depressants or tranquilizers without a doctor's orders?
1. No
2. Yes
Past 12 months, have you used ADHD medication without a doctor's orders?
1. No
2. Yes
My parents/guardians are aware of my alcohol use.
1. Yes
2. No
During your life, have you ever tried ecstasy?
1. Yes
2. No
Have you obtained alcohol from your home during the past 6 months?
1. Never
2. Sometimes
3. Usually
4. Always
5. Don't Use
Have you obtained alcohol from a friend's home during the past 6 months?
1. Never
2. Sometimes
3. Usually
4. Always
5. Don't Use
Have you obtained alcohol at parties, social events (parents WERE present), during the past 6 months?
1. Never
2. Sometimes
3. Usually
4. Always
5. Don't Use
Have you obtained alcohol at parties, social events (parents NOT present), during the past 6 months?
1. Never
2. Sometimes
3. Usually
4. Always
5. Don't Use
Have you obtained alcohol purchased by stranger or known adult during past the 6 months?
1. Never
2. Sometimes
3. Usually
4. Always
5. Don't Use
A friend or someone in my peer group, obtained ecstasy from?
1. Never
2. Sometimes
3. Usually
4. Always
5. Don't Use
At parties, social events or raves, obtained ecstasy from?
1. Never
2. Sometimes
3. Usually
4. Always
5. Don't Use
Drugs/Alcohol, would most likely talk to or get advice/information?
1. Friend
2. Brother/Sister
3. Parent/Guardian
4. Teacher/Counselor
5. Other Adult
6. Internet
7. Hotline/Agency
8. Other
Where do you most often access the internet?
1. I never access the internet
2. Home
3. School
4. Pay-for-use computer facility
5. Community center
6. Elsewhere
How much time do you spend on the internet each week?
1. None/Less than an hour
2. 1 to 5 hours
3. 5 to 10 hours
4. More than 10 hours
Have you ever done an internet search to help you with problems you are having at school, home or elsewhere?
1. Yes
2. No
Does the information you read online help you to change or think about changing your behavior?
1. Yes
2. No
Who do you live with?
1. Mother and father
2. One parent
3. Parent and stepparent
4. Grandparent or other relative
5. Other
How long have you been in the foster care system?
1. Less than one month
2. Six months
3. One year
4. Two years
5. Three years
6. Four years
7. Over five years
8. Over ten years
9. As long as I can remember
10. Not sure
In your opinion, has being in foster care affected your health?
1. No, has not affected my health
2. Positively affected my health
3. Negatively affected my health
4. Not sure
Past 12 months, how often have you been suspended from school?
1. Once
2. Twice
3. 3-6 times
4. 7 or more times
5. Never
Past 12 months, how often have you been absent from school all day without permission?
1. Once
2. Twice
3. 3-6 times
4. 7 or more times
5. Never
I have cheated within the past 30 days on homework, test or written reports.
1. Not at all true
2. A little true
3. Pretty much true
4. Very much true
What grades do you usually receive?
1. Mostly A's
2. Mostly A's and B's
3. Mostly B's
4. Mostly B's and C's
5. Mostly C's
6. Mostly C's and D's
7. Mostly D's
8. Mostly D's and F's
9. Mostly F's
How likely is it that you will attend a four-year college right after you graduate from high school?
1. Not at all likely
2. Somewhat likely
3. Very likely
How likely is it that you will attend a business/vocational college right after you graduate from high school?
1. Not at all likely
2. Somewhat likely
3. Very likely
How likely is it that you will work while going to school right after you graduate from high school?
1. Not at all likely
2. Somewhat likely
3. Very likely
How likely is it that you will work without attending school right after you graduate from high school?
1. Not at all likely
2. Somewhat likely
3. Very likely
How likely is it that you will join the military right after you graduate from high school?
1. Not at all likely
2. Somewhat likely
3. Very likely
I get most of my homework help from:
1. A parent
2. My sister or brother
3. My friends
4. After school program
5. I receive no help on homework
How much time do you spend on your homework each school day?
1. 1/2 hour to 1 hour
2. 1 to 2 hours
3. 2 or more hours
After high school graduation I plan on:
1. Attending a four-year college
2. Attending a community college
3. Attending a trade school
4. Going to work
5. Enlisting in the military
What is your biggest concern about attending college?
1. Do not plan to attend college
2. Do not have any concerns about attending college
3. Cost
4. Classes too hard
5. I may not make friends
6. Lack of family support
7. It takes too much time to go to college
Which is most important when learning about your future choices in colleges and universities?
1. College/university features throughout the U.S
2. Cost of college and financial aid assistance
3. Particular course selection and requirements for admission
4. Local options including community colleges and trade schools
5. No opinion
During the last 12 months, what have you discussed most with your parents/guardian concerning your options after high school graduation?
1. Should I or should I not go to college
2. Particular course selection and requirements for admission
3. Options including 4-year university/community college/trade schools
4. Job possibilities after high school graduation
5. No discussion
During the last 12 months, what have you discussed most with your school counselor?
1. College admission
2. Class schedule and course changes
3. School related issues
4. Personal issues
5. Have not talked to the counselor
Parents know what students need to learn in this school to succeed after graduation, agree?
1. Strongly agree
2. Agree
3. No opinion
4. Disagree
5. Strongly disagree
Students know what they need to learn in this school to succeed after graduation, agree?
1. Strongly agree
2. Agree
3. No opinion
4. Disagree
5. Strongly disagree
I am aware of the career/technical programs in my school.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I am aware of the career/technical programs in my community.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I am being prepared for jobs of the future.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I have had several opportunities to learn pre-employment skills.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I am aware of many options for my future career plans.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
I am saving money now for a future career goal.
1. Not true at all
2. A little true
3. Pretty much true
4. Very much true
This year, what is your grade point average in school?
1. Mostly As
2. Mostly Bs
3. Mostly Cs
4. Mostly Ds
5. Mostly Fs
Bad Grades, would most likely talk to or get advice/information?
1. Friend
2. Brother/Sister
3. Parent/Guardian
4. Teacher/Counselor
5. Other Adult
6. Internet
7. Hotline/Agency
8. Other
I signed up for the (program name) program this school year.
1. No
2. Yes
If you were offered drugs or alcohol within the past year, how many times did you use the (program name) program as a reason to say 'no'?
1. Does not apply - I was never offered drugs or alcohol
2. Does not apply - I didnÕt say 'no'
3. Does not apply - I didn't use the (program) as the reason to say 'no'
4. 1 time
5. 2 to 3 times
6. 4 or more times
How many students do you know that have used the (program name) program as a reason to say 'no'?
1. 0 students
2. 1 student
3. 2 to 3 students
4. 4 or more students
Before deciding to sign-up for the program, I had a discussion with my parent(s) about drug and alcohol use.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
The (program name) program caused me to reduce my drug or alcohol use.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
5. Does not apply - I don't use drugs
The (program name) program makes it easier to avoid drugs when confronted with peer pressure.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
The (program name) program is a helpful tool and should be offered again next year as a voluntary program for students
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
If the (program name) is offered again next school year, I am likely to sign up.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
I participate in the following activities this school year.
1. Fall sport
2. Spring sport
3. Instrumental music
4. Vocal music
5. Drama
Have you participated in Club Live/Friday Night Live since the beginning of this school year?
1. Yes
2. No
3. We don't have this
Have you participated in Safe School Ambassadors since the beginning of this school year?
1. Yes
2. No
3. We don't have this
Have you participated as a mediator in conflict mediation program since the beginning of this school year?
1. Yes
2. No
3. We don't have this
Have you participated as a peer helper in a peer helping program since the beginning of this school year?
1. Yes
2. No
3. We don't have this
Have you participated in as a mentor or tutor in a mentoring or tutoring program since the beginning of this school year?
1. Yes
2. No
3. We don't have this
Have you participated in a school-based service club or group since the beginning of this school year?
1. Yes
2. No
3. We don't have this
Would you like an opportunity to meet with other students to learn about and discuss the results of this survey?
1. Yes
2. No
Did you ever take part in lessons called (name)?
1. No
2. Yes
Past 12 months at school, Have lessons about alcohol and drugs and their effects on the body?
1. No
2. Yes
3. Don't know
Past 12 months at school, Have lessons about the effects of drugs and addiction on the brain?
1. No
2. Yes
3. Don't know
Do you think random student drug-testing prevents student drug use?
1. Yes
2. A lot
3. Some
4. Not much
5. Not at all
I understand the 5-step refusal skill model.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
Have you ever heard of the (name) Youth Project?
1. Yes
2. No
Have you ever called the (name) Youth Project for help with something?
1. Yes
2. No
3. Don't know/don't remember
Have you ever participated in any (name) Youth Project programs either on campus or elsewhere in the community?
1. Yes
2. No
3. Don't know/don't remember
Have you ever received a (name) Youth Project outreach card or 'fry card'?
1. Yes
2. No
Would you feel comfortable calling the (name) Youth Project/any other agency on the card if you needed help?
1. Yes
2. No
How often do you use the fry card to get free fries at McDonald's?
1. Never
2. Few times a year
3. 1 to 3 times a month
4. 1 time a week
5. Other
Have you ever heard of the (name) Youth Project website Ðwww.HelpNotHassle.org?
1. Yes
2. No
Would you feel comfortable using www.HelpNotHassle.org if you needed anonymous and confidential information?
1. Yes
2. No
Past 12 months, Had classes or other training in how to resolve conflicts at school?
1. Yes
2. No
3. Not sure
Past 12 months, had activities to promote respect between racial and ethnic groups at school?
1. Yes
2. No
3. Not sure
Past 12 months, participate in 'free for the weekend' at school?
1. Yes
2. No
3. Not sure
Past 12 months, participate in 'teen court' at school?
1. Yes
2. No
3. Not sure
Past 12 months, helped with 'red ribbon' at school?
1. Yes
2. No
3. Not sure
Past 12 months, tutored younger students at school?
1. Yes
2. No
3. Not sure
Past 12 months, provided community service at school?
1. Yes
2. No
3. Not sure
Past 12 months, took 'peer advocacy' classes at school?
1. Yes
2. No
3. Not sure
Past year, got care when needed for - Counseling for help with stress, depression, or family problems?
1. Always
2. Sometimes
3. Never
4. Don't know/remember
5. Didn't need care
Past year, where usually get - Counseling for help with stress, depression, or family problems?
1. SHC/School Nurse
2. Kaiser
3. Dr's office/Community clinic
4. Emergency room
5. Don't know/remember
Happened in past year - Considered attempting suicide
1. No
2. Yes
Happened in past year - Trouble or difficulties with schoolwork
1. No
2. Yes
Happened in past year - Serious health problems
1. No
2. Yes
Happened in past year - Parents divorced or separated
1. No
2. Yes
Happened in past year - Death of a parent, relative, or close friend
1. No
2. Yes
Happened in past year - Became homeless
1. No
2. Yes
Happened in past year - Got suspended or expelled
1. No
2. Yes
(Program) helped me - Deal with personal and/or family issues
1. No
2. Yes
(Program) helped me - Have goals and plans for the future
1. No
2. Yes
Happened in past year - Didn't feel safe at home
1. No
2. Yes
Happened in past year - Was in a violent fight/attack where someone got hurt
1. No
2. Yes
Happened in past year - Saw a violent fight or crime
1. No
2. Yes
Happened in past year - Was involved in a serious crime
1. No
2. Yes
(Program) helped me - Use tobacco less
1. No
2. Yes
(Program) helped me - Use alcohol or drugs less
1. No
2. Yes
(Program) helped me - Do better in school
1. No
2. Yes
(Program) helped me - Eat better
1. No
2. Yes
Past year, got care when needed for - Help with confidential issues like birth control, condoms, or STDs?
1. Always
2. Sometimes
3. Never
4. Don't know/remember
5. Didn't need care
Past year, where usually get - Help with confidential issues like birth control, condoms, or STDs?
1. SHC/School Nurse
2. Kaiser
3. Dr's office/Community clinic
4. Emergency room
5. Don't know/remember
Happened in past year - Got pregnant or got someone pregnant
1. No
2. Yes
(Program) helped me - Use birth control or condoms more often
1. No
2. Yes
Past year, got care when needed for - Medical care when you were sick or hurt?
1. Always
2. Sometimes
3. Never
4. Don't know/remember
5. Didn't need care
Past year, where usually get - Medical care when you were sick or hurt?
1. SHC/School Nurse
2. Kaiser
3. Dr's office/Community clinic
4. Emergency room
5. Don't know/remember
Have you ever used the School Health Center for information or services?
1. No
2. Yes
Services received from (enter organization name) - Medical care or first aid for injury (cut, bruise, sprain)
1. No
2. Yes
Services received from (enter organization name) - Medical care for sickness (cold/flu, sore throat, cramps, head/stomachache)
1. No
2. Yes
Services received from (enter organization name) - Physical exam, check up or sports physical
1. No
2. Yes
Services received from (enter organization name) - Help with confidential issues like birth control, condoms, or STDs
1. No
2. Yes
Services received from (enter organization name) - Counseling for help with stress, depression, or family problems
1. No
2. Yes
Services received from (enter organization name) - Help with food, clothes, jobs, or places to live
1. No
2. Yes
Services received from (enter organization name) - Other services
1. No
2. Yes
(Program) helped me - Get services I would not otherwise get
1. No
2. Yes
(Program) helped me - Get help sooner than I would otherwise
1. No
2. Yes
(Program) helped me - Get information and resources I need
1. No
2. Yes
Rate how you feel about the (Program) - I like having it at my school.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
Rate how you feel about the (Program) - I would recommend it to my friends.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
The people who work at the (Program) - Are people I trust
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
The people who work at the (Program) - Are people I can go to for advice or information
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
The people who work at the (Program) - Are easier to talk to than doctors or nurses
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
Do you participate in any type of exercise after school is finished?
1. Yes
2. No
3. I'm not sure
Past 12 months, been to a doctor or hospital for wheezing or trouble breathing?
1. No
2. Yes
Past 12 months, when not exercising ever had wheezing, chest tightness, or trouble breathing?
1. No
2. Yes
I am an athelete on a high school athletic team.
1. Yes
2. No
Past 12 months, ever had a dry cough at night, even when you did not have a cold or the flu?
1. No
2. Yes
Past 24 hours, How many times did you drink milk or eat yogurt?
1. 0 times
2. 1 time
3. 2 times
4. 3 times
5. 4 times
6. 5 or more times
Past 24 hours, How many times did you drink soda pop?
1. 0 times
2. 1 time
3. 2 times
4. 3 times
5. 4 times
6. 5 or more times
Past 24 hours, How many times did you eat french fries or potato chips?
1. 0 times
2. 1 time
3. 2 times
4. 3 times
5. 4 times
6. 5 or more times
Past 24 hours, How many times did you eat fruit?
1. 0 times
2. 1 time
3. 2 times
4. 3 times
5. 4 times
6. 5 or more times
Past 24 hours, How many times did you eat vegetables?
1. 0 times
2. 1 time
3. 2 times
4. 3 times
5. 4 times
6. 5 or more times
Did you eat breakfast today?
1. Yes
2. No
So far this school year, how many times has your class gone outside for physical education?
1. 0 times
2. 1-2 times
3. 3-4 times
4. 5-6 times
5. 7-8 times
6. 9-10 times
7. 11-12 times
At school, have you been taught about the disease, Hepatitis C?
1. No
2. Yes
To be healthy, how many servings of fruits and vegetables should you eat each day?
1. 1-2
2. 3-4
3. 5-6
In your opinion, how is your overall health?
1. I am as healthy in mind and body as I could be
2. I could be healthier and plan to do what it takes
3. I could be healthier but don't know what to do about it
4. I am not healthy
5. I am not sure
Have you ever learned anything from health education classes?
1. Never attended
2. Yes, learned to improve overall health
3. No, did not learn anything
4. Not sure
If so, did you learn anything to improve your overall health?
1. Yes
2. No
3. Not sure
How long did the health education class run for?
1. One hour
2. One week
3. One month
4. One quarter
5. One year
How would you compare your health to other students at different high schools?
1. Worse
2. Same
3. Better
4. I don't know
Do you believe your health has improved since arriving at (Program)?
1. Yes
2. No
3. I'm not sure
4. Too soon to tell
Do you participate in a (school/program) team sport such as football, volleyball, or basketball?
1. Yes
2. No
Do you participate in open gym activities?
1. Yes
2. No
Do you think your level of physical activity would increase if more non-structured activities were offered, such as double dutch or foosball?
1. Yes
2. No
Does your 'house' participate in any group exercise such as group walks?
1. Yes
2. No
Does your 'house' provide you with healthy choices for snacks and meals?
1. Yes I am satisfied with the choices
2. Yes but I would like to see more choices
3. I'm not sure
4. No my house doesn't provide me with healthy snacks/meals
Do you believe that this campus promotes a healthy lifestyle?
1. Yes I believe this campus promotes health
2. No I don't believe that this campus promotes health
Would you like to see the salad bar in the cafeteria expanded?
1. Yes
2. No
Would you like to see vegetarian options open to all students and not just students who are designated as being 'vegetarian'?
1. Yes
2. No
Would you like the cafeteria to offer lower fat meal options?
1. Yes
2. No
3. I'm not sure
Would you like the vending machines to offer healthier choices for snacks and drinks?
1. Yes
2. No
3. I'm not sure
Would you like to participate in helping make decisions about healthy choices on campus?
1. Yes
2. No
3. I'm not sure
Have you and your parents sought counseling due to fear that you may have an eating disorder?
1. Yes
2. No
3. Not sure
Has anyone in your family been treated for an eating disorder?
1. Yes
2. No
3. Not sure
How many people in your school do you know who you feel have an eating disorder?
1. None
2. 1 or 2
3. 3 to 5
4. More than 5
Have you ever had sexual intercourse?
1. No
2. Yes
Past 3 months, with how many people have you had sexual intercourse?
1. Not in past 3 months
2. 1 person
3. 2 people
4. 3 people
5. 4 people
6. 5 people
7. 6 or more people
Did you drink or use drugs before you had sexual intercourse the last time?
1. Never had sexual intercourse
2. No
3. Yes
The last time you had sexual intercourse, did you or your partner use a condom?
1. Never had sexual intercourse
2. No
3. Yes
The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy?
1. Never had sexual intercourse
2. No method was used
3. Condoms
4. Withdrawal
5. Foam
6. Some other method
7. Not sure
Have you ever been forced to have sexual intercourse when you did not want to?
1. No
2. Yes
How much do you agree that for teens your age, abstinence is a better choice than having sexual intercourse?
1. Strongly agree
2. Agree
3. Disagree
4. Strongly disagree
Have you ever been taught about AIDS or HIV infection at school?
1. No
2. Yes
3. Not sure
Have you ever talked with a parent or another adult in your family about sex?
1. No
2. Yes
Have you ever talked with a parent or another adult in your family about HIV, the AIDS disease?
1. No
2. Yes
Dating/Relationships, would most likely talk to or get advice/information?
1. Friend
2. Brother/Sister
3. Parent/Guardian
4. Teacher/Counselor
5. Other Adult
6. Internet
7. Hotline/Agency
8. Other

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