Student Health Survey

Study to Examine Web-based Administration of the Youth Risk Behavior Survey

Appendix E1 - Student Health Survey Without Skips

Student Health Survey

OMB: 0920-0763

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Appendix E1. Data Collection Instrument for Students – “Student Health Survey”

Form Approved

OMB No.: 0920-xxxx

Expiration Date: xx/xx/xx



Student Health Survey


This survey is about health behavior. It has been developed so you can tell us what you do that may affect your health. It will also ask you questions about your experience taking this survey. The information you give will be used to develop better health education for young people like yourself.


DO NOT write your name on this survey. The answers you give will be kept private. No one will know what you write. Answer the questions based on what you really do.


Completing the survey is voluntary. Whether or not you answer the questions will not affect your grade in this class. If you are not comfortable answering a question, just leave it blank.


The questions that ask about your background will be used only to describe the types of students completing this survey. The information will not be used to find out your name. No names will ever be reported.


Make sure to read every question. Fill in the ovals completely. When you are finished, follow the instructions of the person giving you the survey.




Thank you very much for your help.






Public reporting burden for this collection of information is estimated to average 45 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-XXXX).

DIRECTIONS

  • Use a #2 pencil only.

  • M ake dark marks.

  • Fill in a response like this: A B C D

  • If you change your answer, erase your old answer completely.


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. Are you Hispanic or Latino?

A . Yes

B. No


5. What is your race? (Select one or more responses.)

A . American Indian or Alaska Native

B . Asian

C. Black or African American

D. Native Hawaiian or Other Pacific Islander

E. White


6. How tall are you without your shoes on?

Directions: Write your height in the shaded blank boxes. Fill in the matching oval below each number.


Example


Height




Height


Feet


Inches




Feet


Inches


5


7








3


0




3


0


4


1




4


1


5


2




5


2


6


3




6


3


7


4




7


4




5






5




6






6




7






7




8






8




9






9




10






10




11






11


7. How much do you weigh without your shoes on?

Directions: Write your weight in the shaded blank boxes. Fill in the matching oval below each number.


Example


Weight




Weight


Pounds




Pounds


1


5


2










0


0


0




0


0


0


1


1


1




1


1


1


2


2


2




2


2


2


3


3


3




3


3


3




4


4






4


4




5


5






5


5




6


6






6


6




7


7






7


7




8


8






8


8



9


9






9


9


The next 4 questions ask about safety.


8. When you rode a bicycle during the past 12 months, how often did you wear a helmet?

A . I did not ride a bicycle during the past 12 months

B . Never wore a helmet

C. Rarely wore a helmet

D . Sometimes wore a helmet

E. Most of the time wore a helmet

F . Always wore a helmet


9. How often do you wear a seat belt when riding in a car driven by someone else?

A . Never

B. Rarely

C . Sometimes

D. Most of the time

E . Always


10. 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?

A . 0 times

B. 1 time

C . 2 or 3 times

D. 4 or 5 times

E . 6 or more times


11. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?

A . 0 times

B. 1 time

C . 2 or 3 times

D. 4 or 5 times

E . 6 or more times


The next 11 questions ask about violence-related behaviors.


12. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club?

A . 0 days

B. 1 day

C. 2 or 3 days

D. 4 or 5 days

E. 6 or more days

13. During the past 30 days, on how many days did you carry a gun?

A . 0 days

B. 1 day

C. 2 or 3 days

D. 4 or 5 days

E. 6 or more days


14. 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


15. 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


16. 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 11 times

H. 12 or more times


17. 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 11 times

H . 12 or more times


18. During the past 12 months, how many times were you in a physical fight?

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 11 times

H . 12 or more times


19. During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?

A . 0 times

B. 1 time

C. 2 or 3 times

D. 4 or 5 times

E. 6 or more times


20. 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 11 times

H . 12 or more times


21. During the past 12 months, did your boyfriend or girlfriend ever hit, slap, or physically hurt you on purpose?

A . Yes

B. No


22. Have you ever been physically forced to have sexual intercourse when you did not want to?

A . Yes

B. No


The next 5 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.


23. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?

A . Yes

B. No


24. During the past 12 months, did you ever seriously consider attempting suicide?

A . Yes

B. No


25. During the past 12 months, did you make a plan about how you would attempt suicide?

A . Yes

B. No


26. 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


27. 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

B. Yes

C. No


The next 11 questions ask about tobacco use.


28. Have you ever tried cigarette smoking, even one or two puffs?

A . Yes

B. No


29. How old were you when you smoked a whole cigarette for the first time?

A . I have never smoked a whole cigarette

B . 8 years old or younger

C. 9 or 10 years old

D . 11 or 12 years old

E. 13 or 14 years old

F . 15 or 16 years old

G . 17 years old or older



30. During the past 30 days, on how many days did you smoke cigarettes?

A . 0 days

B . 1 or 2 days

C . 3 to 5 days

D . 6 to 9 days

E . 10 to 19 days

F . 20 to 29 days

G . All 30 days


31. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?

A . I did not smoke cigarettes during the past 30 days

B . Less than 1 cigarette per day

C . 1 cigarette per day

D. 2 to 5 cigarettes per day

E. 6 to 10 cigarettes per day

F. 11 to 20 cigarettes per day

G. More than 20 cigarettes per day


32. During the past 30 days, how did you usually get your own cigarettes? (Select only one response.)

A . I did not smoke cigarettes during the past 30 days

B . I bought them in a store such as a convenience store, supermarket, discount store, or gas station

C. I bought them from a vending machine

D. I gave someone else money to buy them for me

E. I borrowed (or bummed) them from someone else

F. A person 18 years old or older gave them to me

G . I took them from a store or family member

H . I got them some other way


33. During the past 30 days, on how many days did you smoke cigarettes on school property?

A . 0 days

B. 1 or 2 days

C. 3 to 5 days

D. 6 to 9 days

E. 10 to 19 days

F . 20 to 29 days

G . All 30 days


34. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?

A . Yes

B. No


35. During the past 12 months, did you ever try to quit smoking cigarettes?

A . I did not smoke during the past 12 months

B . Yes

C. No


36. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?

A . 0 days

B . 1 or 2 days

C . 3 to 5 days

D . 6 to 9 days

E . 10 to 19 days

F . 20 to 29 days

G . All 30 days


37. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip on school property?

A . 0 days

B . 1 or 2 days

C . 3 to 5 days

D . 6 to 9 days

E . 10 to 19 days

F . 20 to 29 days

G . All 30 days


38. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?

A . 0 days

B . 1 or 2 days

C . 3 to 5 days

D . 6 to 9 days

E . 10 to 19 days

F . 20 to 29 days

G . All 30 days


The next 6 questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes.


39. During your life, on how many days have you had at least one drink of alcohol?

A . 0 days

B . 1 or 2 days

C . 3 to 9 days

D . 10 to 19 days

E . 20 to 39 days

F . 40 to 99 days

G . 100 or more days


40. How old were you when you had your first drink of alcohol other than a few sips?

A . I have never had a drink of alcohol other than a few sips

B . 8 years old or younger

C. 9 or 10 years old

D . 11 or 12 years old

E. 13 or 14 years old

F . 15 or 16 years old

G . 17 years old or older


41. During the past 30 days, on how many days did you have at least one drink of alcohol?

A . 0 days

B . 1 or 2 days

C . 3 to 5 days

D . 6 to 9 days

E . 10 to 19 days

F . 20 to 29 days

G . All 30 days


42. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?

A . 0 days

B . 1 day

C . 2 days

D . 3 to 5 days

E . 6 to 9 days

F . 10 to 19 days

G . 20 or more days


43. During the past 30 days, how did you usually get the alcohol you drank?

A . I did not drink alcohol during the past 30 days

B . I bought it in a store such as a liquor store, convenience store, supermarket, discount store, or gas station

C. I bought it at a restaurant, bar, or club

D. I bought it at a public event such as a concert or sporting event

E. I gave someone else money to buy it for me

F. Someone gave it to me

G . I took it from a store or family member

H . I got it some other way


44. During the past 30 days, on how many days did you have at least one drink of alcohol on school property?

A . 0 days

B . 1 or 2 days

C . 3 to 5 days

D . 6 to 9 days

E . 10 to 19 days

F . 20 to 29 days

G . All 30 days


The next 4 questions ask about marijuana use. Marijuana also is called grass or pot.


45. During your life, how many times have you used marijuana?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 to 99 times

G . 100 or more times


46. How old were you when you tried marijuana for the first time?

A . I have never tried marijuana

B . 8 years old or younger

C. 9 or 10 years old

D . 11 or 12 years old

E. 13 or 14 years old

F . 15 or 16 years old

G . 17 years old or older


47. During the past 30 days, how many times did you use marijuana?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


48. During the past 30 days, how many times did you use marijuana on school property?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


The next 9 questions ask about other drugs.


49. During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


50. During the past 30 days, how many times did you use any form of cocaine, including powder, crack, or freebase?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


51. During your life, how many times have you sniffed glue, breathed the contents of aerosol spray cans, or inhaled any paints or sprays to get high?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


52. During your life, how many times have you used heroin (also called smack, junk, or China White)?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


53. During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice)?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


54. During your life, how many times have you used ecstasy (also called MDMA)?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


55. During your life, how many times have you taken steroid pills or shots without a doctor's prescription?

A . 0 times

B . 1 or 2 times

C . 3 to 9 times

D . 10 to 19 times

E . 20 to 39 times

F . 40 or more times


56. During your life, how many times have you used a needle to inject any illegal drug into your body?

A . 0 times

B . 1 time

C . 2 or more times


57. During the past 12 months, has anyone offered, sold, or given you an illegal drug on school property?

A . Yes

B . No


The next 7 questions ask about sexual behavior.


58. Have you ever had sexual intercourse?

A . Yes

B . No


59. How old were you when you had sexual intercourse for the first time?

A . I have never had sexual intercourse

B . 11 years old or younger

C . 12 years old

D. 13 years old

E. 14 years old

F. 15 years old

G. 16 years old

H . 17 years old or older


60. During your life, with how many people have you had sexual intercourse?

A . I have never had sexual intercourse

B . 1 person

C . 2 people

D. 3 people

E. 4 people

F. 5 people

G. 6 or more people


61. During the past 3 months, with how many people did you have sexual intercourse?

A . I have never had sexual intercourse

B . I have had sexual intercourse, but not during the past 3 months

C . 1 person

D. 2 people

E. 3 people

F. 4 people

G. 5 people

H . 6 or more people


62. Did you drink alcohol or use drugs before you had sexual intercourse the last time?

A . I have never had sexual intercourse

B . Yes

C . No


63. The last time you had sexual intercourse, did you or your partner use a condom?

A . I have never had sexual intercourse

B . Yes

C . No


64. The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy? (Select only one response.)

A . I have never had sexual intercourse

B . No method was used to prevent pregnancy

C . Birth control pills

D. Condoms

E. Depo-Provera (injectable birth control)

F. Withdrawal

G. Some other method

H . Not sure


The next 7 questions ask about body weight.


65. How do you describe your weight?

A . Very underweight

B . Slightly underweight

C . About the right weight

D . Slightly overweight

E. Very overweight


66. Which of the following are you trying to do about your weight?

A . Lose weight

B . Gain weight

C. Stay the same weight

D. I am not trying to do anything about my weight


67. During the past 30 days, did you exercise to lose weight or to keep from gaining weight?

A . Yes

B . No


68. During the past 30 days, did you eat less food, fewer calories, or foods low in fat to lose weight or to keep from gaining weight?

A . Yes

B . No


69. During the past 30 days, did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?

A . Yes

B . No


70. During the past 30 days, did you take any diet pills, powders, or liquids without a doctor's advice to lose weight or to keep from gaining weight? (Do not include meal replacement products such as Slim Fast.)

A . Yes

B . No


71. During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?

A . Yes

B . No


The next 5 questions ask about physical activity.


72. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spend in any kind of physical activity that increases your heart rate and makes you breathe hard some of the time.)

A . 0 days

B. 1 day

C . 2 days

D. 3 days

E . 4 days

F . 5 days

G . 6 days

H . 7 days


73. On an average school day, how many hours do you watch TV?

A . I do not watch TV on an average school day

B . Less than 1 hour per day

C . 1 hour per day

D. 2 hours per day

E. 3 hours per day

F. 4 hours per day

G. 5 or more hours per day


74. On an average school day, how many hours do you play video or computer games or use a computer for something that is not school work? (Include activities such as Nintendo, Game Boy, PlayStation, Xbox, computer games, and the Internet.)

A . I do not play video or computer games or use a computer for something that is not school work
B . Less than 1 hour per day

C . 1 hour per day

D . 2 hours per day

E. 3 hours per day

F . 4 hours per day

G. 5 or more hours per day


75. In an average week when you are in school, on how many days do you go to physical education (PE) classes?

A . 0 days

B . 1 day

C. 2 days

D. 3 days

E. 4 days

F. 5 days


76. During the past 12 months, on how many sports teams did you play? (Include any teams run by your school or community groups.)

A . 0 teams

B. 1 team

C. 2 teams

D. 3 or more teams


The next question asks about AIDS education.


  1. Have you ever been taught about AIDS or HIV infection in school?

A . Yes

B. No

C. No sure


The next 2 questions ask about missing school.


78. During the past 30 days, on how many days did you miss classes or school for any reason, with or without permission?

A . 0 days

B . 1 day

C . 2 or 3 days

D . 4 or 5 days

E . 6 to 9 days

F . 10 or more days


79. During the past 30 days, on how many days did you miss classes or school without permission?

A . 0 days

B . 1 day

C . 2 or 3 days

D . 4 or 5 days

E . 6 to 9 days

F . 10 or more days


The next 2 questions ask about your experience using computers.


80. On an average school day, how many hours do you use a computer? Include activities such as being on the internet, playing computer games, sending e-mail, and doing homework.

A . I do not use a computer
B . Less than 1 hour per day

C . 1 hour per day

D . 2 hours per day

E. 3 hours per day

F . 4 hours per day

G. 5 or more hours per day


*81. (Before today,) have you ever used a computer to take a survey or test?

A . Yes

B. No


The next 3 questions ask about your experience taking this survey.


82. While taking this survey, could anyone besides you see your answers?

A . Yes

B. No

C. No sure


83. While taking this survey, did you ask anyone about what some questions meant or about what your answers should be?

A . Yes

B. No

84. If you had a choice of taking this survey on the internet or taking this survey using paper and pencil, which would you choose?

A . Internet
B . Paper and pencil

C . It would not matter to me


How much do you agree or disagree with the following 4 statements?


85. I am confident that the answers I gave in this survey will never be linked with my name.

A . Strongly agree
B . Agree

C . Neither agree nor disagree

D . Disagree

E. Strongly disagree


86. I wish I could have taken the survey in a more private place.

A . Strongly agree
B . Agree

C . Neither agree nor disagree

D . Disagree

E. Strongly disagree


*87. Taking this survey on the internet would keep (keeps) it from being private.

A . Strongly agree
B . Agree

C . Neither agree nor disagree

D . Disagree

E. Strongly disagree


88. I am concerned that people I do not know can get personal information about me when I am visiting websites on the internet.

A . Strongly agree
B . Agree

C . Neither agree nor disagree

D . Disagree

E. Strongly disagree


The following 3 (4) questions ask about how you took this survey.


89. How was your class originally asked to take this survey?

A. On paper

B. On a computer

C. Not sure


90. How was your class originally asked to do this survey?

A. As a group in class

B. Individually, on our own time

C. Not sure


91. Did you take this survey at the same time as most of the other students in your class?

A. Yes

B. No

C. Not sure



9 2. Which of the following best describes where you took this survey?**
A. Computer lab at school

B . At school, but not in a computer lab

C . Home

D . Work

E. Friend’s house

F . Public place, such as a library or internet café

G. Somewhere else


*Question wording is for paper-and-pencil condition. Words in parentheses will be used for computer condition.

**Question will appear on web-based questionnaire only.




This is the end of the survey.

Thank you very much for your help.



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