This survey is about health behavior. It has been developed so
you can tell us what you do that may affect your health. The answers you give
are confidential. Please answer the questions based on what you really do.
Please read the questions carefully and answer them as honestly as you can. Your
identity will NOT be revealed. Thank you very much for your help.
1. How old are
you?
(A) 12 years old
or younger
(B) 13 years old
(C) 14 years old
(D) 15 years old
(E) 16 years old
(F) 17 years old
(G) 18 years old
or older
2. What is your
sex?
(A) Female
(B) Male
3. In what grade
are you?
(A) 9th grade
(B) 10th grade
(C) 11th grade
(D) 12th grade
(E) Ungraded or
other grade
4. What school
do you attend?
(A) East Burke
High
(B) Freedom High
(C) J. L. Patton
High
5. How do you
describe yourself? (Select one or more responses.)
1. During the
past 30 days, how many times did you ride in a car or other
vehicle driven by someone who had been drinking alcohol or under
the influence of another drug?
(A) 0 times
(B) 1 time
(C) 2 or 3 times
(D) 4 or 5 times
(E) 6 or more
times
2. During the
past 30 days, how many times did you drive a car or other
vehicle when you had been drinking alcohol or under the
influence of another drug?
The next six questions ask about violence related behaviors.
1. During the
past 30 days, on how many days did you carry a weapon such as a
gun, knife, or club on school property?
(A) 0 days
(B) 1 day
(C) 2 or 3 days
(D) 4 or 5 days
(E) 6 or more
days
2. During the
past 30 days, on how many days did you not go to school because
you felt you would be unsafe at school or on your way to or from
school?
(A) 0 days
(B) 1 day
(C) 2 or 3 days
(D) 4 or 5 days
(E) 6 or more
days
3. During the past 12 months, how many times has
someone threatened or injured you with a weapon such as a gun,
knife, or club on school property?
(A) 0 times
(B) 1 time
(C) 2 or 3 times
(D) 4 or 5 times
(E) 6 or 7 times
(F) 8 or 9 times
(G) 10 or more
times
4. During the
past 12 months, how many times has someone stolen or
deliberately damaged your property such as your car, clothing,
or books on school property?
(A) 0 times
(B) 1 time
(C) 2 or 3 times
(D) 4 or 5 times
(E) 6 or 7 times
(F) 8 or 9 times
(G) 10 or more
times
5. During the
past 12 months, how many times were you in a physical fight on
school property?
(A) 0 times
(B) 1 time
(C) 2 or 3 times
(D) 4 or 5 times
(E) 6 or 7 times
(F) 8 or 9 times
(G) 10 or more
times
6. During the
past 12 months, did your boyfriend or girlfriend ever hit, slap,
or physically hurt you on purpose?
The next 4 questions ask about sad feelings and attempted
suicide. Sometimes people feel so depressed about the future that they may
consider attempting suicide, that is, taking some action to end their own life.
1. During the
past 12 months, did you ever seriously consider attempting
suicide?
(A) yes
(B) No
2. During the
past 12 months, did you make a plan about how you would attempt
suicide?
(A) Yes
(B) No
3. During the
past 12 months, how many times did you actually attempt suicide?
(A) 0 times
(B) 1 time
(C) 2 or 3 times
(D) 4 or 5 times
(E) 6 or more
times
4. 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?
(A) I did not
attempt suicide during the past 12 months
