Health Risk Behavior Survey (high school)

OMB No: ???: Exp Date: ???

Health Risk Behavior Survey

HEALTH AND HEALTH RISK BEHAVIOR QUESTIONNAIRE: CHILD Middle School Version TABLE OF CONTENTS Injury 1 Rule Breaking 2 Tobacco/Alcohol/Drug Use 3 Physical Activity 4 Eating 6 Sleep Behavior 6 School Performance 6 Communication 7

I. Injury The next questions ask about serious injuries that you had in the past year. We want to know about serious injuries that stopped you from doing things like playing, or that made you need to see a doctor, like a broken bone or a cut that required stitches. How many times were you injured in the past 12 months? ___________________________ In the past twelve months, have you had any of the following injuries? (Check all that apply). 2A. An injury related to playing or having fun (for example, while playing on a bicycle or skateboard)? Yes No 2B. A burn or scald? Yes No 2C. A broken bone? Yes No 2D. An animal bite? Yes No

Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

2E. A poison related injury? Yes No 2F. A cut or pierce that required stitches? Yes No 2G. An injury caused by something like a tool or machine? Yes No 3. How often do you wear a seatbelt when riding in a car? Never Rarely Sometimes Most of the time Always 4. How often do you cross the street or run out into the street without checking for cars? Never Rarely Sometimes Most of the time Always 5. How often do you do dangerous things like jumping off high places? Never Rarely Sometimes Most of the time Always 6. When you ride a bicycle, how often do you wear a helmet? I do not ride a bicycle Never Rarely Sometimes Most of the time Always

7. When you roller blade or ride a skateboard, how often do you wear protective gear such as a helmet, wrist guards, or knee pads? I do not roller blade or ride a skateboard Never Rarely Sometimes Most of the time Always 8. In the past 12 months, have you carried a weapon, such as a gun, knife, or club on school property? Yes No 9. In the past 12 months, have you been in a physical fight? Yes No 10. In the past 12 months, have you been in a physical fight in which you were hurt and had to be treated by a doctor or a nurse? Yes No 11. Have you ever tried to intentionally hurt yourself? Yes No II. Rule Breaking These next few questions are very sensitive and ask about breaking rules and laws. You can choose not to answer any of these questions. Remember these questions are private and we will not tell your parents how you answer.

12. When was the last time you stole something worth more than $50? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never 13. When was the last time you were required to appear in court for something you had done? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never 14. When was the last time you were sent to the principal or counselor for disciplinary reasons? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never 15. If you take medication for ADHD (attention deficit/hyperactivity disorder), do you mostly take it yourself without supervision? Yes No I do not take medication for ADHD 16. If you take medication for ADHD, who tells you to take your medication? My parents always remind me Most of the time my parents remind me Most of the time I do it on my own I always remember it on my own I do not take medication for ADHD

17. If you take prescription medication for ADHD: In the past 12 months, did you ever give or sell your medication to others? Yes No I do not take medication for ADHD III. Tobacco/Alcohol/Drug Use These next few questions are very sensitive and ask you about drug use. You can choose not to answer any of these questions. Remember these questions are private and we will not tell your parents how you answer. 18. How old were you when you tried cigarette smoking, even one or two puffs? I have never tried cigarette smoking 8 years old 9 years old 10 years old 11 years old 12 years old 13 years old 19. Do you currently smoke on a regular basis (at least once per week)? Yes No 20. Have you ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen? Yes No 21. Have you ever had a drink of alcohol, other than a few sips? Yes No

22. Have you ever used marijuana (also called grass, pot, weed)? Yes No 23. Have you ever sniffed glue, or breathed the contents of spray cans, or inhaled any paints or sprays to get high? Yes No IV. Physical Activity 24. During the past 7 days on how many days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 25. During the past 7 days, on how many days did you exercise or participate in physical activity for at least 20 minutes that did not make you sweat and breathe hard, such as fast walking, slow bicycling, skating, pushing a lawn mower, or mopping floors? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

26. During the past 7 days on how many days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 27. Do your parent(s) limit the amount of time that you spend watching television? Yes No 28. On an average school day, how many hours do you usually spend reading for fun (books/magazines/newspapers)? I do not read for fun on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 29. On an average school day, how many hours do you watch TV (or DVD/videos)? I do not watch TV on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day

30. On an average school day, how many hours do you listen to music (radio/tapes/CDs/MP3s)? I do not listen to music on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 31. On an average school day, how many hours do you play with video or handheld games? I do not play with video games on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 32. On an average school day, how many hours do you use a computer for something that is not school work? I do not use a computer for something that is not school work on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day

33. On an average school day, how many hours do you use more than one type of media at the same time (like music & computer, or TV & reading)? I do not use more than one type of media on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 34. Do your parent(s) use internet filters or other methods of parental supervision when you are on the Internet or watching television? Yes No 35. Do you have access to R-rated movies and videos or mature rated video games? Yes No 36. Are there family rules about what television programs you are allowed to watch? Yes No 37. In an average week when you are in school, on how many days do you go to physical education (PE) classes? 0 days 1 day 2 days 3 days 4 days 5 days

38. How often do you participate in organized or team sports (include any teams run by your school or community)? I do not participate in organized sports Daily Twice a week Weekly Every other week Once a month Less than once a month 39. Compared to other children your age, do you consider yourself: Much more active than other children Somewhat more active than other children About as active as other children Less active than other children Much less active that other children V. Eating 40. During the past 7 days, how many times did your family eat a meal together? Never Once Twice 3 times 4 times 5 times 6 times 7 or more times

VI. Sleep Behavior 41. On a typical night, do you have trouble sleeping? Yes No 42. Do you snore? Yes No 43. Are you a restless sleeper? Yes No 44. Do you wake up during the night? Yes No 45. How many hours of sleep do you get on a typical night? More than 8 hours 6-8 hours 4-5 hours Less than 4 hours 46. Are you sleepy during the day? Yes No VII. School Performance 47. Has someone from school or a doctor ever told you that you have a learning disability? Yes No

48. Do you consider yourself an: A student B student C student D student F student 49. Do you worry about how you are doing right now or in the future? Yes No VIII. Communication 50. How much have your parent(s) spoken with you about not smoking? Not at all Somewhat A moderate amount A great deal 51. How much have your parent(s) spoken with you about not drinking? Not at all Somewhat A moderate amount A great deal

52. How much have your parent(s) spoken with you about not using drugs? Not at all Somewhat A moderate amount A great deal 53. How much have your parent(s) spoken with you about birth control? Not at all Somewhat A moderate amount A great deal 54. How much have your parent(s) spoken with you about sexually transmitted diseases? Not at all Somewhat A moderate amount A great deal

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by