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pdfAttachment 1: Data Collection Instruments
1. Student Survey: Grade 10
2. Student Survey: Grades 7-8-9
3. Student Survey: Grade 6
OMB No.: 0925-0557
Expiration Date: 01/31/2009
10
2009–10
Health Behaviors in School Age Children Survey
Public reporting burden for this collection of information is estimated to average 40 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0557). Do not return the completed form to this address.
This survey asks about your health. It is being given to thousands of young people throughout the U.S. and in many other
countries. The information you give will be used to develop better programs for young people like yourself.
This survey is anonymous. DO NOT write your name anywhere on this survey booklet. No one will know what you write.
A computer will record the answers. Answer the questions based on what you really do, think, and feel. There are some
questions that describe the types of students answering this survey. We do not want anyone’s name. Completing the
survey is voluntary. Whether or not you answer the questions will not affect your grade in any class.
Make sure you read every question. You do not have to answer any question that makes you feel uncomfortable. When
you are finished, follow the instructions of the person giving you the survey.
Instructions for Completing the Survey
Read all the printed answers before marking your choice.
Mark the circle for the one answer that best fits your situation.
Use a No. 2 pencil.
Make heavy marks that fill the circle for your answer.
Erase cleanly any answer you wish to change.
Please do not make stray marks of any kind.
For all the questions, except questions 6, 16, and 17, you should mark only one
circle for your answer in the column below the question, as shown here:
EXAMPLE: Are you a boy or a girl?
Boy
Girl
Sometimes you will be asked to select one choice for each statement. For these questions,
make sure to “Darken one circle on each line” as shown here:
Example: How often do you do each of the following: (Darken one circle on each line)
Often
a. Swim
b. Bowl
c. Play Tennis
Sometimes Never
7. Here is a picture of a ladder. The top of the
ladder ‘10’ is the best possible life for you and
the bottom ‘0’ is the worst possible life for you.
In general, where on the ladder do you feel you
stand at the moment? (Mark the circle next to the
number that best describes where you stand)
TODAY’S DATE
Month
October
November
December
January
February
March
April
May
Day
0
1
2
3
0
1
2
3
4
5
6
7
8
9
10 Best possible life
9
8
7
6
5
4
1. Are you a boy or a girl?
Boy
Girl
2. What month were you born?
Jan
May
Feb
June
Mar
July
Apr
Aug
3a. What year were you born?
1989
1992
1990
1993
1991
1994
3
2
1
Sept
Oct
Nov
Dec
0 Worst possible life
8. Do you think your body is…?
Much too thin
A bit too thin
About the right size
A bit too fat
Much too fat
1995
1996
3b. How old are you?
10 or younger 13
11
14
12
15
16
17 or older
4. What grade are you in?
Grade 6
Grade 8
Grade 7
Grade 9
Grade 10
9. About how many hours a day do you usually
play games on a computer or games console
(Playstation, Xbox, GameCube etc.) in your free
time? (Please mark one circle for weekdays and one
circle for weekend)
Weekdays
Weekend
0
None at all
None at all
About half an hour
About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day
About 2 hours a day
About 3 hours a day
About 3 hours a day
About 4 hours a day
About 4 hours a day
About 5 hours a day
About 5 hours a day
About 6 hours a day
About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
5. What do you consider your ethnicity to be?
Hispanic or Latino
Not Hispanic or Latino
6. What do you consider your race to be?
(Mark all that apply)
Black or African American
White
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
___________________________________
2
10. About how many hours a day do you usually
use a computer for chatting on-line, internet,
emailing, homework etc. in your free time?
(Please mark one circle for weekdays and one circle
for weekend)
All families are different (for example, not everyone
lives with both their parents. Sometimes people
live with just one parent, or they have two homes
or live with two families) and we would like to
know about yours.
Weekdays
Weekend
None at all
None at all
About half an hour About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day About 2 hours a day
About 3 hours a day About 3 hours a day
About 4 hours a day About 4 hours a day
About 5 hours a day About 5 hours a day
About 6 hours a day About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
16. Please answer this question for the home
where you live all or most of the time and check
all the people who live there.
Adults
Mother
Father
Stepmother (or father's girlfriend)
Stepfather (or mother's boyfriend)
Grandmother
Grandfather
I live in a foster home or children's home
Someone or somewhere else: please write
down their relationship to you
____________________________________
11. How well off do you think your family is?
Very well off
Quite well off
Average
Not very well off
Not at all well off
12. How many computers does your family own?
None
One
Two
More than two
Children
Please say how many brothers and sisters live here
(including half, step or foster brothers and sisters).
13. Do you have your own bedroom for
yourself?
No
Yes
Please write in the number or write 0 (zero) if there
are none.
How many
brothers? __________
14. Does your family own a car, van or truck?
No
Yes, one
Yes, two or more
15. During the past 12 months, how many times did
you travel away on vacation with your family?
Not at all
Once
Twice
More than twice
3
How many
sisters? ___________
17. Do you have another home or another family,
such as the case when your parents are
separated or divorced?
No - GO TO QUESTION 18
Yes
How often do you stay there?
Half the time
Regularly but less than half the time
At weekends
Sometimes
Hardly ever
Physical activity is any activity that increases your
heart rate and makes you get out of breath some
of the time. Physical activity can be done in sports,
school activities, playing with friends, or walking to
school.
Some examples of physical activity are running,
brisk walking, rollerblading, biking, dancing,
skateboarding, swimming, soccer, basketball,
football, & surfing.
Please mark all the people who live there:
For this next question, add up all the time you
spent in physical activity each day.
Adults
Mother
Father
Stepmother (or father's girlfriend)
Stepfather (or mother's boyfriend)
Grandmother
Grandfather
I live in a foster home or children's home
Someone or somewhere else: please write
down their relationship to you
____________________________________
19. Over the past 7 days, on how many days were
you physically active for a total of at least 60
minutes per day?
0 days
4 days
1 day
5 days
2 days
6 days
3 days
7 days
20. OUTSIDE SCHOOL HOURS: How OFTEN do you
usually exercise in your free time so much that
you get out of breath or sweat?
Every day
4 to 6 times a week
2 to 3 times a week
Once a week
Once a month
Less than once a month
Never
Children
Please say how many brothers and sisters live here
(including half, step or foster brothers and sisters).
Please write in the number or write 0 (zero) if there
are none.
How many
brothers? __________
21. OUTSIDE SCHOOL HOURS: How many HOURS
a week do you usually exercise in your free time
so much that you get out of breath or sweat?
None
About half an hour
About 1 hour
About 2 to 3 hours
About 4 to 6 hours
7 hours or more
How many
sisters? ___________
18. About how many hours a day do you usually
watch television (including videos and DVDs)
in your free time? (Please mark one circle for
weekdays and one circle for weekend)
Weekdays
Weekend
None at all
None at all
About half an hour About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day About 2 hours a day
About 3 hours a day About 3 hours a day
About 4 hours a day About 4 hours a day
About 5 hours a day About 5 hours a day
About 6 hours a day About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
22. How long does it usually take you to travel to
school from your home? (Please mark one circle only)
Less than 5 minutes
5-15 minutes
15-30 minutes
30 minutes to 1 hour
More than 1 hour
4
28. How often do you have an evening meal
together with your mother or father?
Never
Less than once a week
1-2 days a week
3-4 days a week
5-6 days a week
Every day
23. On a typical day is the MAIN part of your trip
TO school made by…? (Please mark one circle only)
Walking
Bicycle
Bus, train, tram, underground or boat
Car, motorcycle or moped
Other means
24. On a typical day is the MAIN part of your trip
FROM school made by…? (Please mark one circle only)
Walking
Bicycle
Bus, train, tram, underground or boat
Car, motorcycle or moped
Other means
29. Where do you usually eat your mid-day meal on
schooldays?
At school
At home
At someone else's home
In a snack-bar, fast food restaurant, café
Somewhere else: Please write down where:
_____________________________________
I never eat a mid-day meal
25. How often do you usually have breakfast (more
than a glass of milk or fruit juice)?
(Please mark one circle for weekdays and one circle
for weekend)
30. How often do you eat a snack while you…….?
Never
Less than once a week
1-2 days a week
3-4 days a week
5-6 days a week
Every day
Weekdays
Weekend
0
I never have
I never have breakfast
breakfast during during the weekend
I usually have breakfast
weekdays
One day
on only one day of the
Two days weekend (Saturday OR
Three days
Sunday
Four days
I usually have breakfast
Five days on both weekend days
(Saturday AND Sunday)
a. Watch TV (including videos
and DVDs)?
b. Work or play on a computer
or games console?
26. How many times a week do you usually eat or
drink...? (Please mark one circle for each line)
31. How often do you eat in a fast food restaurant
(for example, McDonalds, KFC, Pizza Hut, Taco
Bell)?
Never
Rarely (less than once a month)
Once a month
2-3 times a month
Once a week
2-4 days a week
5 or more days a week
Never
Less than once a week
Once a week
2-4 days a week
5-6 days a week
Once a day, every day
Every day, more than once
a. Fruits
b. Vegetables
c. Sweets (candy or chocolate)
d. Coke or other soft drinks that
contain sugar
27. How often do you have breakfast together with
your mother or father?
Never
Less than once a week
1-2 days a week
3-4 days a week
5-6 days a week
Every day
5
32. Some young people go to school or to bed
hungry because there is not enough food at
home. How often does this happen to you?
Always
Often
Sometimes
Never
33. How much do you weigh without clothes? (In
pounds)
28
Example
Weight
Weight
1
5
2
0
1
2
3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
0
1
2
3
4
5
6
7
8
9
38. Here are some statements about one’s feelings
of his/her body. There are no right or wrong
answers. We would like to know what your
feelings of your body are. Please evaluate how
the statements relate to you by checking the
degree to which you agree or disagree with
each one. (Please check one box for each line.)
0
1
2
3
4
5
6
7
8
9
32
a. I am frustrated with my physical
appearance
b. I am satisfied with my appearance
c. I hate my body
d. I feel comfortable with my body
e. I feel anger toward my body
f. I like my appearance in spite of
its imperfections
34. How tall are you without shoes?
29
Example
Feet
Inches
5
2
0
1
2
3
4
5
6
7
0
1
2
3
4
5
6
7
8
9
10
11
Feet
Inches
0
1
2
3
4
5
6
7
0
1
2
3
4
5
6
7
8
9
10
11
I do not agree at all
Disagree
Neither agree or disagree
Agree
Strongly agree
GIRLS ONLY
39. Have you begun to menstruate (have periods)?
No, I have not yet begun to menstruate
Yes, I have begun to menstruate.
Please indicate the age you were when you
began to menstruate. For example, if you began
3 months after your 13th birthday you would
indicate the age of 13 years and 3 months.
I began at the age of ______ years and
______ months.
BOYS ONLY
35. When did you last weigh yourself?
Within the last week
Within the last month
Within the last 6 months
More than 6 months ago
40. Have you begun to grow hair on your face?
Not yet started
Barely started
Definitely underway
Seems completed
36. When did you last measure your height?
Within the last week
Within the last month
Within the last 6 months
More than 6 months ago
41. How often do you brush your teeth?
More than once a day
Once a day
At least once a week but not daily
Less than once a week
Never
37. At present are you on a diet or doing something
else to lose weight?
No, my weight is fine
No, but I should lose some weight
No, because I need to put on weight
Yes
6
42. In the last 6 months: how often have you had the
following…? (Please mark one circle for each line)
39
45c. Does your long-term illness, disability or
medical condition affect your attendance and
participation at school?
I do not have a long-term illness, disability or
medical condition
Yes
No
About every day
About every week
More than once a week
About every month
Rarely or never
46. Thinking about last week......
a. Headache
b. Stomach-ache
c. Back ache
d. Feeling low
e. Irritability or bad temper
f. Feeling nervous
g. Difficulties in getting to sleep
h. Feeling dizzy
45
Extremely/Always
Very/Very often
Moderately/Quite often
Slightly/Seldom
Not at all/Never
a. Have you felt fit and well?
b. Have you felt full of energy?
c. Have you felt sad?
d. Have you felt lonely?
e. Have you had enough time for
yourself?
f. Have you been able to do the
things that you want to do in your
free time?
g. Have your parent(s) treated you
fairly?
h. Have you had fun with your friends?
i. Have you got on well at school?
j. Have you been able to pay
attention?
43. During the last month have you taken any
medicine or tablets for the following?
Yes, more
No Yes than once
a. Headache
b. Stomach-ache
c. Difficulties in
getting to sleep
d. Nervousness
e. Allergy
f. Something else
44. Would you say your health is……? (Please mark
one circle)
Excellent
Fair
Good
Poor
Many young people get hurt or injured from activities such as playing sports or fighting with others at
different places such as the street or home. Injuries
can include being poisoned or burned. Injuries
do not include illnesses such as Measles or the Flu.
The following questions are about injuries you may
have had during the past 12 months.
45a.Do you have a long-term illness, disability,
or medical condition (like diabetes, arthritis,
asthma, allergy, ADHD, or cerebral palsy) that
has been diagnosed by a doctor?
No
Yes
If Yes, please write what they are.
_________________________________________
_
45b.Do you take medicine for your long-term
illness, disability or medical condition?
I do not have a long-term illness, disability or
medical condition
Yes
No
47. During the past 12 months, how many times
were you injured and had to be treated by a
doctor or nurse?
I was not injured in the past 12 months
1 time
2 times
3 times
4 times or more
7
51. My parent/guardian… (Please mark one circle for
each line)
48. How easy is it for you to talk to the following
persons about things that really bother you?
(Please mark one circle for each line)
50
Very easy
Easy
47
Difficult
Very difficult
Don’t have or see this person
Almost always
Sometimes
Almost never
a. Helps me as much as I need
b. Lets me do the things I like doing
c. Is loving
d. Understands my problems and worries
e. Likes me to make my own decisions
f. Tries to control everything I do
g. Treats me like a baby
h. Makes me feel better when I am upset
a. Father
b. Stepfather (or mother’s boyfriend)
c. Mother
d. Stepmother (or father’s girlfriend)
e. Elder brother (s)
f. Elder sister (s)
g. Best friend
h. Friends of the same sex
i. Friends of the opposite sex
52. In general, how satisfied are you with the
relationships in your family? (Mark one circle
next to the number that best describes your feelings.)
10 We have very good relationships in our family
9
8
7
6
5
4
3
2
1
0 We have very bad relationships in our family
49. How much does your mother (or female
guardian) really know about…?
She knows a lot
She
knows
a little
48
She doesn’t know anything
Don’t have/see mother/guardian
a. Who your friends are
b. How you spend your money
c. Where you are after school
d. Where you go at night
e. What you do with your free time
53. At present, how many close male and female
friends do you have? (Please mark one circle each
column)
Males
0
None
One
Two
Three or more
50. How much does your father (or male guardian)
really know about…?
He knows a lot
He knows a little
49
He doesn’t know anything
Don’t have/see father/guardian
Females
None
One
Two
Three or more
54. Are MOST of the friends in your group...
More or less your same age (same grade)
Older than you (by one grade or more)
Younger than you (by one grade or more)
a. Who your friends are
b. How you spend your money
c. Where you are after school
d. Where you go at night
e. What you do with your free time
55. How many days a week do you usually spend
time with friends right after school?
0 days
1
2
3
4
5
6 days
8
0
56. How many evenings per week do you usually
spend out with your friends?
0 evenings
1
2
3
4
5
6
7 evenings
61. Here are some statements about the students
in your class(es). Please show how much you
agree or disagree with each one. (Please mark
one circle for each line)
60
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
a. The students in my class(es) enjoy
being together
b. Most of the students in my class(es)
are kind and helpful
c. Other students accept me as I am
57. How often do you talk to your friend(s) on
the phone or send them text messages or have
contact through the internet?
Rarely or never
1 or 2 days a week
3 or 4 days a week
5 or 6 days a week
Every day
62. How pressured do you feel by the schoolwork
you have to do?
Not at all
A little
Some
A lot
58. Your group of friends is well accepted by your
parents?
Almost always
Sometimes
Never, almost never
They haven’t met your group of friends
Here are some questions about bullying. We say a
student is BEING BULLIED when another student, or
a group of students, say or do nasty and unpleasant
things to him or her. It is also bullying when a student is teased repeatedly in a way he or she does
not like or when he or she is deliberately left out of
things. But it is NOT BULLYING when two students
of about the same strength or power argue or fight.
It is also not bullying when a student is teased in a
friendly and playful way.
59. In your opinion, what does your class teacher(s)
think about your school performance compared
to your classmates?
Very good
Good
Average
Below average
60. How do you feel about school at present?
I like it a lot
I like it a bit
I don’t like it very much
I don’t like it at all
63. How often have you been bullied at school in
the past couple of months?
I haven’t been bullied at school the past couple
of months
It has only happened once or twice
2 or 3 times a month
About once a week
Several times a week
9
66. How often have you bullied another student(s)
at school in the past couple of months in the
ways listed below? (Please mark one circle for
each line)
Several times a week
About once a week
65
2 or 3 times a month
Only once or twice
I have not bullied another student in
this way in the past couple of months
64. How often have you been bullied at school in the
past couple of months in the ways listed below?
(Please mark one circle for each line)
Several times a week
About
once a week
63
2 or 3 times a month
Only once or twice
I have not been bullied in this
way in the past couple of months
a. I called another student(s) mean
names, and made fun of, or teased
him or her in a hurtful way
b. I kept another student(s) out of
things on purpose, excluded him
or her from my group of friends, or
completely ignored him or her
c. I hit, kicked, pushed, shoved around,
or locked another student(s) indoors
d. I spread false rumors about another
student(s) and tried to make others
dislike him or her
e. I bullied another student(s) with
mean names and comments about
his or her race or color
f. I bullied another student(s) with
mean names and comments about
his or her religion
g. I made sexual jokes, comments, or
gestures to another student(s)
h. I was bullied using a computer or
e-mail messages or pictures
i. I bullied another student(s) using a
cell phone
a. I was called mean names, was made
fun of, or teased in a hurtful way
b. Other students left me out of things
on purpose, excluded me from their
group of friends, or completely
ignored me
c. I was hit, kicked, pushed, shoved
around, or locked indoors
d. Other students told lies or spread
false rumors about me and tried to
make others dislike me
e. I was bullied with mean names and
comments about my race or color
f. I was bullied with mean names and
comments about my religion.
g. Other students made sexual jokes,
comments, or gestures to me
h. I was bullied using a computer or
e-mail messages or pictures
i. I was bullied using a cell phone
65. How often have you taken part in bullying
another student(s) at school in the past couple
of months?
I haven’t bullied another student(s) at school in
the past couple of months
It has only happened once or twice
2 or 3 times a month
About once a week
Several times a week
67. During the past 12 months, how many times
were you in a physical fight?
I have not been in a physical fight
1 time
2 times
3 times
4 times or more
68. The last time you were in a physical fight during
the past 12 months, with whom did you fight?
I have not been in a physical fight in the past
12 months
A total stranger
A parent or other adult family member
A brother or sister
A boyfriend/girlfriend or date
A friend or someone I know
Someone not listed above
10
69. During the past 30 days, on how many days did
you carry a weapon, such as a gun, knife or club?
I did not carry a weapon during the past 30 days
1 day
2 to 3 days
4 to 5 days
6 or more days
74. On how many occasions (if any) have you done
the following things in the last 30 days? (Please
mark one circle for each line.)
72
70. The last time you carried a weapon during the
past 30 days, what type of weapon was it?
I did not carry a weapon during the past 30 days
Knife or pocketknife
Stick or club
Knuckle-brace/brass knuckles
Tear gas/pepper spray/Mace
Handgun or other firearm
Other type, please specify:
________________________
a. Smoked cigarettes
b. Drunk alcohol
c. Been drunk
75. How frequently have you smoked cigarettes
during the LAST 30 DAYS?
Not at all
Less than 1 cigarette per week
Less than 1 cigarette per day
1-5 cigarettes per day
6-10 cigarettes per day
11-20 cigarettes per day
More than 20 cigarettes per day
71. Have you ever smoked tobacco? (At least one
cigarette, cigar or pipe)
No
Yes
72. How often do you smoke tobacco at present?
Every day
At least once a week, but not every day
Less than once a week
I do not smoke
76. How many of your friends would you
estimate…
74
73. At present, how often do you drink anything
alcoholic, such as beer, wine or hard liquor like,
Vodka or rum? Try to include even those times
when you only drink a small amount (e.g. one
or two sips). (Please mark one circle for each line)
71
Never
Once or twice
3-5 times
6-9 times
10-19 times
20-39 times
40 times or more
None
A few
Some
Most
All
a. Smoke cigarettes
b. Drink alcohol
c. Get drunk at least once a week
d. Smoke/use marijuana,
(pot, weed, hash, joint)
e. Carry a weapon, such as gun, knife,
or club
Every day
Every week
Every month
Rarely
Never
a. Beer
b. Wine
c. Liquor/Spirits
d. Pre-mixed drinks (for example,
Smirnoff Ice, Bacardi Breezer,
Mike’s Hard Lemonade)
e. Any other drink that contains alcohol
77. Have you ever had so much alcohol that you
were really drunk?
No, never
Yes, once
Yes, 2-3 times
Yes, 4-10 times
Yes, more than 10 times
11
78. At what age did you first do the following
things? (If there is something you have not done,
choose the ‘never’ category)
81. Father—Does your father have a job?
No
Don’t know
Yes
Don’t have or don’t see father
a. Drink alcohol (more than a small amount)
Never
I was __ years old (Write in the box how old you were)
b. Get drunk
Never
I was __ years old (Write in the box how old you were)
c. Smoke a cigarette (more than a puff)
Never
I was __ years old (Write in the box how old you were)
If YES, please say in what place he works
(for example: hospital, bank, restaurant)
_____________________________________
Please write down exactly what job he does
there (for example: teacher, bus driver)
_____________________________________
If NO, why does your father not have a job?
(Please mark the circle that best describes the situation)
He is sick, or retired, or a student
He is looking for a job
He takes care of others, or is full-time in the home
I don’t know
79. Have you ever taken marijuana (pot, weed,
hashish, joint)? (Please mark one circle for each line)
78
Never
Once or twice
3-5 times
6-9 times
10-19 times
20-39 times
40 times or more
82. MOTHER—Does your mother have a job?
No
Don’t know
Yes
Don’t have or don’t see mother
If YES, please say in what place she works
(for example: hospital, bank, restaurant)
a. In your life
b. In the last 12 months
c. In the last 30 days
_____________________________________
Please write down exactly what job she does
there (for example: teacher, bus driver)
80. Have you ever taken one or several of these
drugs in the last 12 months? (Please mark one
circle for each line)
Never
Once
or
twice
75
3-5 times
6-9 times
10-19 times
20-39 times
40 times or more
a. Ecstasy
b. Amphetamines (meth, ice,
glass, speed)
c. Opiates (heroin, morphine,
smack)
d. Medication to get high
e. Cocaine
f. Glue or solvents
g. Baltok
h. LSD
i. Anabolic steroids
j. Other drug
Which one? _______________
_____________________________________
If NO, why does your mother not have a job?
(Please mark the circle that best describes the situation)
She is sick, or retired, or a student
She is looking for a job
She takes care of others, or is full-time in the home
I don’t know
83. Were you born in the United States?
Yes
No
84. Which country was your mother born?
_______________________________
Don’t know
85. Which country was your father born?
_______________________________
Don’t know
86. What language do you most often speak at
home?
_______________________________________
This is the end of the survey.
If there is time, please go back and review each question to be sure you have answered all the questions and followed the directions.
THANK YOU VERY MUCH FOR YOUR HELP!
10
12
OMB No.: 0925-0557
Expiration Date: 01/31/2009
7-8-9
2009–10
Health Behaviors in School Age Children Survey
Public reporting burden for this collection of information is estimated to average 40 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0557). Do not return the completed form to this address.
This survey asks about your health. It is being given to thousands of young people throughout the U.S. and in many other
countries. The information you give will be used to develop better programs for young people like yourself.
This survey is anonymous. DO NOT write your name anywhere on this survey booklet. No one will know what you write.
A computer will record the answers. Answer the questions based on what you really do, think, and feel. There are some
questions that describe the types of students answering this survey. We do not want anyone’s name. Completing the
survey is voluntary. Whether or not you answer the questions will not affect your grade in any class.
Make sure you read every question. You do not have to answer any question that makes you feel uncomfortable. When
you are finished, follow the instructions of the person giving you the survey.
Instructions for Completing the Survey
Read all the printed answers before marking your choice.
Mark the circle for the one answer that best fits your situation.
Use a No. 2 pencil.
Make heavy marks that fill the circle for your answer.
Erase cleanly any answer you wish to change.
Please do not make stray marks of any kind.
For all the questions, except questions 6, 16, and 17, you should mark only one
circle for your answer in the column below the question, as shown here:
EXAMPLE: Are you a boy or a girl?
Boy
Girl
Sometimes you will be asked to select one choice for each statement. For these questions,
make sure to “Darken one circle on each line” as shown here:
Example: How often do you do each of the following: (Darken one circle on each line)
Often
a. Swim
b. Bowl
c. Play Tennis
Sometimes Never
7. Here is a picture of a ladder. The top of the
ladder ‘10’ is the best possible life for you and
the bottom ‘0’ is the worst possible life for you.
In general, where on the ladder do you feel you
stand at the moment? (Mark the circle next to the
number that best describes where you stand)
TODAY’S DATE
Month
October
November
December
January
February
March
April
May
Day
0
1
2
3
0
1
2
3
4
5
6
7
8
9
10 Best possible life
9
8
7
6
5
4
1. Are you a boy or a girl?
Boy
Girl
2. What month were you born?
Jan
May
Feb
June
Mar
July
Apr
Aug
3a. What year were you born?
1989
1992
1990
1993
1991
1994
3
2
1
Sept
Oct
Nov
Dec
0 Worst possible life
8. Do you think your body is…?
Much too thin
A bit too thin
About the right size
A bit too fat
Much too fat
1995
1996
3b. How old are you?
10 or younger 13
11
14
12
15
16
17 or older
4. What grade are you in?
Grade 6
Grade 8
Grade 7
Grade 9
Grade 10
9. About how many hours a day do you usually
play games on a computer or games console
(Playstation, Xbox, GameCube etc.) in your free
time? (Please mark one circle for weekdays and one
circle for weekend)
Weekdays
Weekend
0
None at all
None at all
About half an hour
About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day
About 2 hours a day
About 3 hours a day
About 3 hours a day
About 4 hours a day
About 4 hours a day
About 5 hours a day
About 5 hours a day
About 6 hours a day
About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
5. What do you consider your ethnicity to be?
Hispanic or Latino
Not Hispanic or Latino
6. What do you consider your race to be?
(Mark all that apply)
Black or African American
White
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
___________________________________
2
10. About how many hours a day do you usually
use a computer for chatting on-line, internet,
emailing, homework etc. in your free time?
(Please mark one circle for weekdays and one circle
for weekend)
All families are different (for example, not everyone
lives with both their parents. Sometimes people
live with just one parent, or they have two homes
or live with two families) and we would like to
know about yours.
Weekdays
Weekend
None at all
None at all
About half an hour About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day About 2 hours a day
About 3 hours a day About 3 hours a day
About 4 hours a day About 4 hours a day
About 5 hours a day About 5 hours a day
About 6 hours a day About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
16. Please answer this question for the home
where you live all or most of the time and check
all the people who live there.
Adults
Mother
Father
Stepmother (or father's girlfriend)
Stepfather (or mother's boyfriend)
Grandmother
Grandfather
I live in a foster home or children's home
Someone or somewhere else: please write
down their relationship to you
____________________________________
11. How well off do you think your family is?
Very well off
Quite well off
Average
Not very well off
Not at all well off
12. How many computers does your family own?
None
One
Two
More than two
Children
Please say how many brothers and sisters live here
(including half, step or foster brothers and sisters).
13. Do you have your own bedroom for
yourself?
No
Yes
Please write in the number or write 0 (zero) if there
are none.
How many
brothers? __________
14. Does your family own a car, van or truck?
No
Yes, one
Yes, two or more
15. During the past 12 months, how many times did
you travel away on vacation with your family?
Not at all
Once
Twice
More than twice
3
How many
sisters? ___________
17. Do you have another home or another family,
such as the case when your parents are
separated or divorced?
No - GO TO QUESTION 18
Yes
How often do you stay there?
Half the time
Regularly but less than half the time
At weekends
Sometimes
Hardly ever
Physical activity is any activity that increases your
heart rate and makes you get out of breath some
of the time. Physical activity can be done in sports,
school activities, playing with friends, or walking to
school.
Some examples of physical activity are running,
brisk walking, rollerblading, biking, dancing,
skateboarding, swimming, soccer, basketball,
football, & surfing.
Please mark all the people who live there:
For this next question, add up all the time you
spent in physical activity each day.
Adults
Mother
Father
Stepmother (or father's girlfriend)
Stepfather (or mother's boyfriend)
Grandmother
Grandfather
I live in a foster home or children's home
Someone or somewhere else: please write
down their relationship to you
____________________________________
19. Over the past 7 days, on how many days were
you physically active for a total of at least 60
minutes per day?
0 days
4 days
1 day
5 days
2 days
6 days
3 days
7 days
20. OUTSIDE SCHOOL HOURS: How OFTEN do you
usually exercise in your free time so much that
you get out of breath or sweat?
Every day
4 to 6 times a week
2 to 3 times a week
Once a week
Once a month
Less than once a month
Never
Children
Please say how many brothers and sisters live here
(including half, step or foster brothers and sisters).
Please write in the number or write 0 (zero) if there
are none.
How many
brothers? __________
21. OUTSIDE SCHOOL HOURS: How many HOURS
a week do you usually exercise in your free time
so much that you get out of breath or sweat?
None
About half an hour
About 1 hour
About 2 to 3 hours
About 4 to 6 hours
7 hours or more
How many
sisters? ___________
18. About how many hours a day do you usually
watch television (including videos and DVDs)
in your free time? (Please mark one circle for
weekdays and one circle for weekend)
Weekdays
Weekend
None at all
None at all
About half an hour About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day About 2 hours a day
About 3 hours a day About 3 hours a day
About 4 hours a day About 4 hours a day
About 5 hours a day About 5 hours a day
About 6 hours a day About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
22. How long does it usually take you to travel to
school from your home? (Please mark one circle only)
Less than 5 minutes
5-15 minutes
15-30 minutes
30 minutes to 1 hour
4
28. How often do you have an evening meal
together with your mother or father?
Never
Less than once a week
1-2 days a week
3-4 days a week
5-6 days a week
Every day
23. On a typical day is the MAIN part of your trip
TO school made by…? (Please mark one circle only)
Walking
Bicycle
Bus, train, tram, underground or boat
Car, motorcycle or moped
Other means
24. On a typical day is the MAIN part of your trip
FROM school made by…? (Please mark one circle only)
Walking
Bicycle
Bus, train, tram, underground or boat
Car, motorcycle or moped
Other means
29. Where do you usually eat your mid-day meal on
schooldays?
At school
At home
At someone else's home
In a snack-bar, fast food restaurant, café
Somewhere else: Please write down where:
____________________________________
I never eat a mid-day meal
25. How often do you usually have breakfast (more
than a glass of milk or fruit juice)?
(Please mark one circle for weekdays and one circle
for weekend)
30. How often do you eat a snack while you…….?
Never
Less than once a week
1-2 days a week
3-4 days a week
5-6 days a week
Every day
Weekdays
Weekend
0
I never have
I never have breakfast
breakfast during during the weekend
I usually have breakfast
weekdays
One day
on only one day of the
Two days weekend (Saturday OR
Three days
Sunday
Four days
I usually have breakfast
Five days on both weekend days
(Saturday AND Sunday)
a. Watch TV (including videos
and DVDs)
b. Work or play on a computer
or games console
26. How many times a week do you usually eat or
drink...? (Please mark one circle for each line)
31. How often do you eat in a fast food restaurant
(for example, McDonalds, KFC, Pizza Hut, Taco
Bell)?
Never
Rarely (less than once a month)
Once a month
2-3 times a month
Once a week
2-4 days a week
5 or more days a week
Never
Less than once a week
Once a week
2-4 days a week
5-6 days a week
Once a day, every day
Every day, more than once
a. Fruits
b. Vegetables
c. Sweets (candy or chocolate)
d. Coke or other soft drinks that
contain sugar
27. How often do you have breakfast together with
your mother or father?
Never
Less than once a week
1-2 days a week
3-4 days a week
5-6 days a week
Every day
5
32. Some young people go to school or to bed
hungry because there is not enough food at
home. How often does this happen to you?
Always
Often
Sometimes
Never
38. Here are some statements about one’s feelings
of his/her body. There are no right or wrong
answers. We would like to know what your
feelings of your body are. Please evaluate how
the statements relate to you by checking the
degree to which you agree or disagree with
each one. (Please check one box for each line.)
33. How much do you weigh without clothes? (In
pounds)
28
Example
Weight
Weight
1
5
2
0
1
2
3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
32
a. I am frustrated with my physical
appearance
b. I am satisfied with my appearance
c. I hate my body
d. I feel comfortable with my body
e. I feel anger toward my body
f. I like my appearance in spite of
its imperfections
34. How tall are you without shoes?
29
Example
Feet
Inches
5
2
0
1
2
3
4
5
6
7
0
1
2
3
4
5
6
7
8
9
10
11
Feet
Inches
0
1
2
3
4
5
6
7
0
1
2
3
4
5
6
7
8
9
10
11
I do not agree at all
Disagree
Neither agree or disagree
Agree
Strongly agree
GIRLS ONLY
39. Have you begun to menstruate (have periods)?
No, I have not yet begun to menstruate
Yes, I have begun to menstruate. Please indicate
the age you were when you began to
menstruate. For example, if you began 3 months
after your 13th birthday you would indicate the
age of 13 years and 3 months.
I began at the age of ______ years and
______ months.
BOYS ONLY
35. When did you last weigh yourself?
Within the last week
Within the last month
Within the last 6 months
More than 6 months ago
40. Have you begun to grow hair on your face?
Not yet started
Barely started
Definitely underway
Seems completed
36. When did you last measure your height?
Within the last week
Within the last month
Within the last 6 months
More than 6 months ago
41. How often do you brush your teeth?
More than once a day
Once a day
At least once a week but not daily
Less than once a week
Never
37. At present are you on a diet or doing something
else to lose weight?
No, my weight is fine
No, but I should lose some weight
No, because I need to put on weight
Yes
6
42. In the last 6 months: how often have you had the
following…? (Please mark one circle for each line)
39
47. Does your long-term illness, disability or
medical condition affect your attendance and
participation at school?
I do not have a long-term illness, disability or
medical condition
Yes
No
About every day
About every week
More than once a week
About every month
Rarely or never
a. Headache
b. Stomach-ache
c. Back ache
d. Feeling low
e. Irritability or bad temper
f. Feeling nervous
g. Difficulties in getting to sleep
h. Feeling dizzy
48. Thinking about last week......
45
Extremely/Always
Very/Very often
Moderately/Quite often
Slightly/Seldom
Not at all/Never
a. Have you felt fit and well?
b. Have you felt full of energy?
c. Have you felt sad?
d. Have you felt lonely?
e. Have you had enough time for
yourself?
f. Have you been able to do the
things that you want to do in your
free time?
g. Have your parent(s) treated you
fairly?
h. Have you had fun with your friends?
i. Have you got on well at school?
j. Have you been able to pay
attention?
43. During the last month have you taken any
medicine or tablets for the following?
Yes, more
No Yes than once
a. Headache
b. Stomach-ache
c. Difficulties in
getting to sleep
d. Nervousness
e. Allergy
f. Something else
44. Would you say your health is……? (Please mark
one circle)
Excellent
Fair
Good
Poor
Many young people get hurt or injured from activities such as playing sports or fighting with others at
different places such as the street or home. Injuries
can include being poisoned or burned. Injuries
do not include illnesses such as Measles or the Flu.
The following questions are about injures you may
have had during the past 12 months.
45. Do you have a long-term illness, disability,
or medical condition (like diabetes, arthritis,
asthma, allergy, ADHD or cerebral palsy) that
has been diagnosed by a doctor?
No
Yes
If Yes, please write what they are.
_________________________________________
_
46. Do you take medicine for your long-term illness,
disability or medical condition?
I do not have a long-term illness, disability or
medical condition
Yes
No
49. During the past 12 months, how many times
were you injured and had to be treated by a
doctor or nurse?
I was not injured in the past 12 months
1 time
2 times
3 times
4 times or more
7
53. My parent/guardian… (Please mark one circle for
each line)
50. How easy is it for you to talk to the following
persons about things that really bother you?
(Please mark one circle for each line)
Almost always
Sometimes
Almost never
50
Very easy
Easy
47
Difficult
Very difficult
Don’t have or see this person
a. Helps me as much as I need
b. Lets me do the things I like doing
c. Is loving
d. Understands my problems and worries
e. Likes me to make my own decisions
f. Tries to control everything I do
g. Treats me like a baby
h. Makes me feel better when I am upset
a. Father
b. Stepfather (or mother’s boyfriend)
c. Mother
d. Stepmother (or father’s girlfriend)
e. Elder brother (s)
f. Elder sister (s)
g. Best friend
h. Friends of the same sex
i. Friends of the opposite sex
54. In general, how satisfied are you with the
relationships in your family? (Mark one circle
next to the number that best describes your feelings.)
10 We have very good relationships in our family
9
8
7
6
5
4
3
2
1
0 We have very bad relationships in our family
51. How much does your mother (or female
guardian) really know about…?
She knows a lot
She
knows
a little
48
She doesn’t know anything
Don’t have/see mother/guardian
a. Who your friends are
b. How you spend your money
c. Where you are after school
d. Where you go at night
e. What you do with your free time
55. At present, how many close male and female
friends do you have? (Please mark one circle each
column)
Males
52. How much does your father (or male guardian)
really know about…?
None
One
Two
Three or more
He knows a lot
He
knows
a little
49
He doesn’t know anything
Don’t have/see father/guardian
0
Females
None
One
Two
Three or more
56. Are MOST of the friends in your group...
More or less your same age (same grade)
Older than you (by one grade or more)
Younger than you (by one grade or more)
a. Who your friends are
b. How you spend your money
c. Where you are after school
d. Where you go at night
e. What you do with your free time
57. How many days a week do you usually spend
time with friends right after school?
0 days
1
2
3
4
5
6 days
8
0
58. How many evenings per week do you usually
spend out with your friends?
0 evenings
1
2
3
4
5
6
7 evenings
63. Here are some statements about the students
in your class(es). Please show how much you
agree or disagree with each one. (Please mark
one circle for each line)
60
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
a. The students in my class(es) enjoy
being together
b. Most of the students in my class(es)
are kind and helpful
c. Other students accept me as I am
59. How often do you talk to your friend(s) on
the phone or send them text messages or have
contact through the internet?
Rarely or never
1 or 2 days a week
3 or 4 days a week
5 or 6 days a week
Every day
64. How pressured do you feel by the schoolwork
you have to do?
Not at all
A little
Some
A lot
60. Your group of friends is well accepted by your
parents?
Almost always
Sometimes
Never, almost never
They haven’t met your group of friends
Here are some questions about bullying. We say a
student is BEING BULLIED when another student, or
a group of students, say or do nasty and unpleasant
things to him or her. It is also bullying when a student is teased repeatedly in a way he or she does
not like or when he or she is deliberately left out of
things. But it is NOT BULLYING when two students
of about the same strength or power argue or fight.
It is also not bullying when a student is teased in a
friendly and playful way.
61. In your opinion, what does your class teacher(s)
think about your school performance compared
to your classmates?
Very good
Good
Average
Below average
62. How do you feel about school at present?
I like it a lot
I like it a bit
I don’t like it very much
I don’t like it at all
65. How often have you been bullied at school in
the past couple of months?
I haven’t been bullied at school the past couple
of months
It has only happened once or twice
2 or 3 times a month
About once a week
Several times a week
9
68. How often have you bullied another student(s)
at school in the past couple of months in the
ways listed below? (Please mark one circle for
each line)
Several times a week
About once a week
65
2 or 3 times a month
Only once or twice
I have not bullied another student in
this way in the past couple of months
66. How often have you been bullied at school in the
past couple of months in the ways listed below?
(Please mark one circle for each line)
Several times a week
About once a week
63
2 or 3 times a month
Only once or twice
I have not been bullied in this
way in the past couple of months
a. I called another student(s) mean
names, and made fun of, or teased
him or her in a hurtful way
b. I kept another student(s) out of
things on purpose, excluded him
or her from my group of friends, or
completely ignored him or her
c. I hit, kicked, pushed, shoved around,
or locked another student(s) indoors.
d. I spread false rumors about another
student(s) and tried to make others
dislike him or her
e. I bullied another student(s) with
mean names and comments about
his or her race or color
f. I bullied another student(s) with
mean names and comments about
his or her religion
g. I made sexual jokes, comments, or
gestures to another student(s)
h. I was bullied using a computer or
e-mail messages or pictures
i. I bullied another student(s) using a
cell phone
a. I was called mean names, was made
fun of, or teased in a hurtful way
b. Other students left me out of things
on purpose, excluded me from their
group of friends, or completely
ignored me
c. I was hit, kicked, pushed, shoved
around, or locked indoors
d. Other students told lies or spread
false rumors about me and tried to
make others dislike me
e. I was bullied with mean names and
comments about my race or color
f. I was bullied with mean names and
comments about my religion.
g. Other students made sexual jokes,
comments, or gestures to me
h. I was bullied using a computer or
e-mail messages or pictures
i. I was bullied using a cell phone
67. How often have you taken part in bullying
another student(s) at school in the past couple
of months?
I haven’t bullied another student(s) at school in
the past couple of months
It has only happened once or twice
2 or 3 times a month
About once a week
Several times a week
69. During the past 12 months, how many times
were you in a physical fight?
I have not been in a physical fight
1 time
2 times
3 times
4 times or more
70. The last time you were in a physical fight during
the past 12 months, with whom did you fight?
I have not been in a physical fight in the past
12 months
A total stranger
A parent or other adult family member
A brother or sister
A boyfriend/girlfriend or date
A friend or someone I know
Someone not listed above
10
71. During the past 30 days, on how many days did
you carry a weapon, such as a gun, knife or club?
I did not carry a weapon during the past 30 days
1 day
2 to 3 days
4 to 5 days
6 or more days
76. On how many occasions (if any) have you done
the following things in the last 30 days? (Please
mark one circle for each line.)
72
72. The last time you carried a weapon during the
past 30 days, what type of weapon was it?
I did not carry a weapon during the past 30 days
Knife or pocketknife
Stick or club
Knuckle-brace/brass knuckles
Tear gas/pepper spray/Mace
Handgun or other firearm
Other type, please specify:
_____________________________________
a. Smoked cigarettes
b. Drunk alcohol
c. Been drunk
77. How frequently have you smoked cigarettes
during the LAST 30 DAYS?
Not at all
Less than 1 cigarette per week
Less than 1 cigarette per day
1-5 cigarettes per day
6-10 cigarettes per day
11-20 cigarettes per day
More than 20 cigarettes per day
73. Have you ever smoked tobacco? (At least one
cigarette, cigar or pipe)
No
Yes
74. How often do you smoke tobacco at present?
Every day
At least once a week, but not every day
Less than once a week
I do not smoke
78. How many of your friends would you
estimate…
74
75. At present, how often do you drink anything
alcoholic, such as beer, wine or hard liquor like,
Vodka or rum? Try to include even those times
when you only drink a small amount (e.g. one
or two sips). (Please mark one circle for each line)
71
Never
Once or twice
3-5 times
6-9 times
10-19 times
20-39 times
40 times or more
None
A few
Some
Most
All
a. Smoke cigarettes
b. Drink alcohol
c. Get drunk at least once a week
d. Smoke/use marijuana,
(pot, weed, hash, joint)
e. Carry a weapon, such as gun, knife,
or club
Every day
Every week
Every month
Rarely
Never
a. Beer
b. Wine
c. Liquor/Spirits
d. Pre-mixed drinks (for example,
Smirnoff Ice, Bacardi Breezer,
Mike’s Hard Lemonade)
e. Any other drink that contains alcohol
79. Have you ever had so much alcohol that you
were really drunk?
No, never
Yes, once
Yes, 2-3 times
Yes, 4-10 times
Yes, more than 10 times
11
80. Have you ever taken marijuana (pot, weed,
hashish, joint)? (Please mark one circle for each line)
78
82. MOTHER—Does your mother have a job?
No
Don’t know
Yes
Don’t have or don’t see mother
Never
Once or twice
3-5 times
6-9 times
10-19 times
20-39 times
40 times or more
If YES, please say in what place she works
(for example: hospital, bank, restaurant)
_____________________________________
Please write down exactly what job she does
there (for example: teacher, bus driver)
a. In your life
b. In the last 12 months
c. In the last 30 days
_____________________________________
If NO, why does your mother not have a job?
(Please mark the circle that best describes the situation)
She is sick, or retired, or a student
She is looking for a job
She takes care of others, or is full-time in the home
I don’t know
81. Father—Does your father have a job?
No
Don’t know
Yes
Don’t have or don’t see father
If YES, please say in what place he works
(for example: hospital, bank, restaurant)
83. Were you born in United States?
Yes
No
_____________________________________
Please write down exactly what job he does
there (for example: teacher, bus driver)
84. Which country was your mother born?
_____________________________________
__________________________________
Don’t know
If NO, why does your father not have a job?
(Please mark the circle that best describes the situation)
He is sick, or retired, or a student
He is looking for a job
He takes care of others, or is full-time in the home
I don’t know
85. Which country was your father born?
__________________________________
Don’t know
86. What language do you most often speak at
home?
__________________________________
This is the end of the survey.
If there is time, please go back and review each question to be sure you have answered all the questions and followed the directions.
THANK YOU VERY MUCH FOR YOUR HELP!
7-8-9
12
OMB No.: 0925-0557
Expiration Date: 01/31/2009
6
2009–10
Health Behaviors in School Age Children Survey
Public reporting burden for this collection of information is estimated to average 40 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0557). Do not return the completed form to this address.
This survey asks about your health. It is being given to thousands of young people throughout the U.S. and in many other
countries. The information you give will be used to develop better programs for young people like yourself.
This survey is anonymous. DO NOT write your name anywhere on this survey booklet. No one will know what you write.
A computer will record the answers. Answer the questions based on what you really do, think, and feel. There are some
questions that describe the types of students answering this survey. We do not want anyone’s name. Completing the
survey is voluntary. Whether or not you answer the questions will not affect your grade in any class.
Make sure you read every question. You do not have to answer any question that makes you feel uncomfortable. When
you are finished, follow the instructions of the person giving you the survey.
Instructions for Completing the Survey
Read all the printed answers before marking your choice.
Mark the circle for the one answer that best fits your situation.
Use a No. 2 pencil.
Make heavy marks that fill the circle for your answer.
Erase cleanly any answer you wish to change.
Please do not make stray marks of any kind.
For all the questions, except questions 6, 16, and 17, you should mark only one
circle for your answer in the column below the question, as shown here:
EXAMPLE: Are you a boy or a girl?
Boy
Girl
Sometimes you will be asked to select one choice for each statement. For these questions,
make sure to “Darken one circle on each line” as shown here:
Example: How often do you do each of the following: (Darken one circle on each line)
Often
a. Swim
b. Bowl
c. Play Tennis
Sometimes Never
7. Here is a picture of a ladder. The top of the
ladder ‘10’ is the best possible life for you and
the bottom ‘0’ is the worst possible life for you.
In general, where on the ladder do you feel you
stand at the moment? (Mark the circle next to the
number that best describes where you stand)
TODAY’S DATE
Month
October
November
December
January
February
March
April
May
Day
0
1
2
3
0
1
2
3
4
5
6
7
8
9
10 Best possible life
9
8
7
6
5
4
1. Are you a boy or a girl?
Boy
Girl
2. What month were you born?
Jan
May
Feb
June
Mar
July
Apr
Aug
3a. What year were you born?
1989
1992
1990
1993
1991
1994
3
2
1
Sept
Oct
Nov
Dec
0 Worst possible life
8. Do you think your body is…?
Much too thin
A bit too thin
About the right size
A bit too fat
Much too fat
1995
1996
3b. How old are you?
10 or younger 13
11
14
12
15
16
17 or older
4. What grade are you in?
Grade 6
Grade 8
Grade 7
Grade 9
Grade 10
9. About how many hours a day do you usually
play games on a computer or games console
(Playstation, Xbox, GameCube etc.) in your free
time? (Please mark one circle for weekdays and one
circle for weekend)
Weekdays
Weekend
0
None at all
None at all
About half an hour
About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day
About 2 hours a day
About 3 hours a day
About 3 hours a day
About 4 hours a day
About 4 hours a day
About 5 hours a day
About 5 hours a day
About 6 hours a day
About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
5. What do you consider your ethnicity to be?
Hispanic or Latino
Not Hispanic or Latino
6. What do you consider your race to be?
(Mark all that apply)
Black or African American
White
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
___________________________________
2
10. About how many hours a day do you usually
use a computer for chatting on-line, internet,
emailing, homework etc. in your free time?
(Please mark one circle for weekdays and one circle
for weekend)
All families are different (for example, not everyone
lives with both their parents. Sometimes people
live with just one parent, or they have two homes
or live with two families) and we would like to
know about yours.
Weekdays
Weekend
None at all
None at all
About half an hour About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day About 2 hours a day
About 3 hours a day About 3 hours a day
About 4 hours a day About 4 hours a day
About 5 hours a day About 5 hours a day
About 6 hours a day About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
16. Please answer this question for the home
where you live all or most of the time and check
all the people who live there.
Adults
Mother
Father
Stepmother (or father's girlfriend)
Stepfather (or mother's boyfriend)
Grandmother
Grandfather
I live in a foster home or children's home
Someone or somewhere else: please write
down their relationship to you
____________________________________
11. How well off do you think your family is?
Very well off
Quite well off
Average
Not very well off
Not at all well off
12. How many computers does your family own?
None
One
Two
More than two
Children
Please say how many brothers and sisters live here
(including half, step or foster brothers and sisters).
13. Do you have your own bedroom for
yourself?
No
Yes
Please write in the number or write 0 (zero) if there
are none.
How many
brothers? __________
14. Does your family own a car, van or truck?
No
Yes, one
Yes, two or more
15. During the past 12 months, how many times did
you travel away on vacation with your family?
Not at all
Once
Twice
More than twice
3
How many
sisters? ___________
17. Do you have another home or another family,
such as the case when your parents are
separated or divorced?
No - GO TO QUESTION 18
Yes
How often do you stay there?
Half the time
Regularly but less than half the time
At weekends
Sometimes
Hardly ever
Physical activity is any activity that increases your heart
rate and makes you get out of breath some of the
time. Physical activity can be done in sports, school
activities, playing with friends, or walking to school.
Some examples of physical activity are running,
brisk walking, rollerblading, biking, dancing,
skateboarding, swimming, soccer, basketball,
football, & surfing.
For this next question, add up all the time you
spent in physical activity each day.
Please mark all the people who live there:
Adults
Mother
Father
Stepmother (or father's girlfriend)
Stepfather (or mother's boyfriend)
Grandmother
Grandfather
I live in a foster home or children's home
Someone or somewhere else: please write
down their relationship to you
____________________________________
19. Over the past 7 days, on how many days were
you physically active for a total of at least 60
minutes per day?
0 days
4 days
1 day
5 days
2 days
6 days
3 days
7 days
20. OUTSIDE SCHOOL HOURS: How OFTEN do you
usually exercise in your free time so much that
you get out of breath or sweat?
Every day
4 to 6 times a week
2 to 3 times a week
Once a week
Once a month
Less than once a month
Never
Children
Please say how many brothers and sisters live here
(including half, step or foster brothers and sisters).
Please write in the number or write 0 (zero) if there
are none.
How many
brothers? __________
21. OUTSIDE SCHOOL HOURS: How many HOURS
a week do you usually exercise in your free time
so much that you get out of breath or sweat?
None
About half an hour
About 1 hour
About 2 to 3 hours
About 4 to 6 hours
7 hours or more
How many
sisters? ___________
18. About how many hours a day do you usually
watch television (including videos and DVDs)
in your free time? (Please mark one circle for
weekdays and one circle for weekend)
22. How long does it usually take you to travel to
school from your home? (Please mark one circle only)
Less than 5 minutes
5-15 minutes
15-30 minutes
30 minutes to 1 hour
Weekdays
Weekend
None at all
None at all
About half an hour About half an hour
a day a day
About 1 hour a day
About 1 hour a day
About 2 hours a day About 2 hours a day
About 3 hours a day About 3 hours a day
About 4 hours a day About 4 hours a day
About 5 hours a day About 5 hours a day
About 6 hours a day About 6 hours a day
About 7 or more
About 7 or more
hours a day hours a day
23. On a typical day is the MAIN part of your trip
TO school made by…? (Please mark one circle only)
Walking
Bicycle
Bus, train, tram, underground or boat
Car, motorcycle or moped
Other means
4
28. Some young people go to school or to bed
hungry because there is not enough food at
home. How often does this happen to you?
Always
Often
Sometimes
Never
24. On a typical day is the MAIN part of your trip
FROM school made by…? (Please mark one circle
only)
Walking
Bicycle
Bus, train, tram, underground or boat
Car, motorcycle or moped
Other means
29. How much do you weigh without clothes? (In
pounds)
28
Example
Weight
Weight
25. How often do you usually have breakfast (more
than a glass of milk or fruit juice)?
(Please mark one circle for weekdays and one circle
for weekend)
Weekdays
0 Weekend
0
I never have
I never have breakfast
breakfast during during the weekend
I usually have breakfast
weekdays
One day
on only one day of the
Two days weekend (Saturday OR
Three days
Sunday
Four days
I usually have breakfast
Five days on both weekend days
(Saturday AND Sunday)
26. How often do you eat in a fast food restaurant
(for example, McDonalds, KFC, Pizza Hut, Taco
Bell)?
Never
Rarely (less than once a month)
Once a month
2-3 times a month
Once a week
2-4 days a week
5 or more days a week
5
2
0
1
2
3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
30. How tall are you without shoes?
29
Example
27. How many times a week do you usually eat or
drink...? (Please mark one circle for each line)
Never
Less than once a week
Once a week
2-4 days a week
5-6 days a week
Once a day, every day
Every day, more than once
a. Fruits
b. Vegetables
c. Sweets (candy or chocolate)
d. Coke or other soft drinks that
contain sugar
1
Feet
Inches
5
2
0
1
2
3
4
5
6
7
0
1
2
3
4
5
6
7
8
9
10
11
Feet
Inches
0
1
2
3
4
5
6
7
0
1
2
3
4
5
6
7
8
9
10
11
31. When did you last weigh yourself?
Within the last week
Within the last month
Within the last 6 months
More than 6 months ago
32. When did you last measure your height?
Within the last week
Within the last month
Within the last 6 months
More than 6 months ago
5
33. At present are you on a diet or doing something
else to lose weight?
No, my weight is fine
No, but I should lose some weight
No, because I need to put on weight
Yes
37. How often do you brush your teeth?
More than once a day
Once a day
At least once a week but not daily
Less than once a week
Never
38. In the last 6 months: how often have you had the
following…? (Please mark one circle for each line)
34. Here are some statements about one’s feelings
of his/her body. There are no right or wrong
answers. We would like to know what your
feelings of your body are. Please evaluate how
the statements relate to you by checking the
degree to which you agree or disagree with
each one. (Please mark one circle for each line.)
32
39
I do not agree at all
Disagree
Neither agree or disagree
Agree
Strongly agree
About every day
About every week
More than once a week
About every month
Rarely or never
a. Headache
b. Stomach-ache
c. Back ache
d. Feeling low
e. Irritability or bad temper
f. Feeling nervous
g. Difficulties in getting to sleep
h. Feeling dizzy
a. I am frustrated with my physical
appearance
b. I am satisfied with my appearance
c. I hate my body
d. I feel comfortable with my body
e. I feel anger toward my body
f. I like my appearance in spite of
its imperfections
39. During the last month have you taken any
medicine or tablets for the following?
Yes, Yes, more
No Once than once
a. Headache
b. Stomach-ache
c. Difficulties in
getting to sleep
d. Nervousness
e. Allergy
f. Something else
GIRLS ONLY
35. Have you begun to menstruate (have periods)?
No, I have not yet begun to menstruate
Yes, I have begun to menstruate. Please indicate
the age you were when you began to
menstruate. For example, if you began 3 months
after your 13th birthday you would indicate the
age of 13 years and 3 months.
I began at the age of ______ years and
______ months.
40. Would you say your health is……? (Please mark
one circle)
Excellent
Fair
Good
Poor
BOYS ONLY
41. Do you have a long-term illness, disability,
or medical condition (like diabetes, arthritis,
asthma, allergy, ADHD or cerebral palsy) that
has been diagnosed by a doctor?
No
Yes
If Yes, please write what they are.
_________________________________________
_
36. Have you begun to grow hair on your face?
Not yet started
Barely started
Definitely underway
Seems completed
6
42. Do you take medicine for your long-term illness,
disability or medical condition?
I do not have a long-term illness, disability or
medical condition
Yes
No
45. During the past 12 months, how many times
were you injured and had to be treated by a
doctor or nurse?
I was not injured in the past 12 months
1 time
2 times
3 times
4 times or more
43. Does your long-term illness, disability or
medical condition affect your attendance and
participation at school?
I do not have a long-term illness, disability or
medical condition
Yes
No
46. How easy is it for you to talk to the following
persons about things that really bother you?
(Please mark one circle for each line)
Very easy
Easy
47
Difficult
Very difficult
Don’t have or see this person
44. Thinking about last week......
45
Extremely/Always
Very/Very often
Moderately/Quite often
Slightly/Seldom
Not at all/Never
a. Father
b. Stepfather (or mother’s boyfriend)
c. Mother
d. Stepmother (or father’s girlfriend)
e. Elder brother (s)
f. Elder sister (s)
g. Best friend
h. Friends of the same sex
i. Friends of the opposite sex
a. Have you felt fit and well?
b. Have you felt full of energy?
c. Have you felt sad?
d. Have you felt lonely?
e. Have you had enough time for
yourself?
f. Have you been able to do the
things that you want to do in your
free time?
g. Have your parent(s) treated you
fairly?
h. Have you had fun with your friends?
i. Have you got on well at school?
j. Have you been able to pay
attention?
47. How much does your mother (or female
guardian) really know about…?
She knows a lot
She
knows
a little
48
She doesn’t know anything
Don’t have/see mother/guardian
a. Who your friends are
b. How you spend your money
c. Where you are after school
d. Where you go at night
e. What you do with your free time
Many young people get hurt or injured from activities such as playing sports or fighting with others at
different places such as the street or home. Injuries
can include being poisoned or burned. Injuries
do not include illnesses such as Measles or the Flu.
The following questions are about injures you may
have had during the past 12 months.
7
52. How many evenings per week do you usually
spend out with your friends?
0 evenings
1
2
3
4
5
6
7 evenings
48. How much does your father (or male guardian)
really know about…?
He knows a lot
He
knows
a little
49
He doesn’t know anything
Don’t have/see father/guardian
a. Who your friends are
b. How you spend your money
c. Where you are after school
d. Where you go at night
e. What you do with your free time
53. How often do you talk to your friend(s) on
the phone or send them text messages or have
contact through the internet?
Rarely or never
1 or 2 days a week
3 or 4 days a week
5 or 6 days a week
Every day
49. In general, how satisfied are you with the
relationships in your family? (Mark one circle
next to the number that best describes your feelings.)
10 We have very good relationships in our family
9
8
7
6
5
4
3
2
1
0 We have very bad relationships in our family
54. In your opinion, what does your class teacher(s)
think about your school performance compared
to your classmates?
Very good
Good
Average
Below average
55. How do you feel about school at present?
I like it a lot
I like it a bit
I don’t like it very much
I don’t like it at all
50. At present, how many close male and female
friends do you have? (Please mark one circle each
column)
Males
None
One
Two
Three or more
0
Females
None
One
Two
Three or more
0
56. Here are some statements about the students
in your class(es). Please show how much you
agree or disagree with each one. (Please mark
one circle for each line)
51. How many days a week do you usually spend
time with friends right after school?
0 days
1
2
3
4
5
6 days
60
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
a. The students in my class(es) enjoy
being together
b. Most of the students in my class(es)
are kind and helpful
c. Other students accept me as I am
57. How pressured do you feel by the schoolwork
you have to do?
Not at all
A little
Some
A lot
8
60. How often have you taken part in bullying
another student(s) at school in the past couple
of months?
I haven’t bullied another student(s) at school in
the past couple of months
It has only happened once or twice
2 or 3 times a month
About once a week
Several times a week
Here are some questions about bullying. We say a
student is BEING BULLIED when another student, or
a group of students, say or do nasty and unpleasant
things to him or her. It is also bullying when a student is teased repeatedly in a way he or she does
not like or when he or she is deliberately left out of
things. But it is NOT BULLYING when two students
of about the same strength or power argue or fight.
It is also not bullying when a student is teased in a
friendly and playful way.
61. How often have you bullied another student(s)
at school in the past couple of months in the
ways listed below? (Please mark one circle for
each line)
58. How often have you been bullied at school in
the past couple of months?
I haven’t been bullied at school the past couple
of months
It has only happened once or twice
2 or 3 times a month
About once a week
Several times a week
Several times a week
About once a week
65
2 or 3 times a month
Only once or twice
I have not bullied another student in
this way in the past couple of months
a. I called another student(s) mean
names, and made fun of, or teased
him or her in a hurtful way
b. I kept another student(s) out of
things on purpose, excluded him
or her from my group of friends, or
completely ignored him or her
c. I hit, kicked, pushed, shoved around,
or locked another student(s) indoors
d. I spread false rumors about another
student(s) and tried to make others
dislike him or her
e. I bullied another student(s) with
mean names and comments about
his or her race or color
f. I bullied another student(s) with
mean names and comments about
his or her religion
g. I made sexual jokes, comments, or
gestures to another student(s)
h. I was bullied using a computer or
e-mail messages or pictures
i. I bullied another student(s) using a
cell phone
59. How often have you been bullied at school in the
past couple of months in the ways listed below?
(Please mark one circle for each line)
Several times a week
About
once a week
63
2 or 3 times a month
Only once or twice
I have not been bullied in this
way in the past couple of months
a. I was called mean names, was made
fun of, or teased in a hurtful way
b. Other students left me out of things
on purpose, excluded me from their
group of friends, or completely
ignored me
c. I was hit, kicked, pushed, shoved
around, or locked indoors
d. Other students told lies or spread
false rumors about me and tried to
make others dislike me
e. I was bullied with mean names and
comments about my race or color
f. I was bullied with mean names and
comments about my religion
g. Other students made sexual jokes,
comments, or gestures to me
h. I was bullied using a computer or
e-mail messages or pictures
i. I was bullied using a cell phone
9
67. How frequently have you smoked cigarettes
during the LAST 30 DAYS?
Not at all
Less than 1 cigarette per week
Less than 1 cigarette per day
1-5 cigarettes per day
6-10 cigarettes per day
11-20 cigarettes per day
More than 20 cigarettes per day
62. During the past 12 months, how many times
were you in a physical fight?
I have not been in a physical fight
1 time
2 times
3 times
4 times or more
63. Have you ever smoked tobacco? (At least one
cigarette, cigar or pipe)
No
Yes
68. How many of your friends would you
estimate…
64. How often do you smoke tobacco at present?
Every day
At least once a week, but not every day
Less than once a week
I do not smoke
74
a. Smoke cigarettes
b. Drink alcohol
c. Get drunk at least once a week
d. Smoke/use marijuana,
(pot, weed, hash, joint)
e. Carry a weapon, such as gun, knife,
or club
65. At present, how often do you drink anything
alcoholic, such as beer, wine or hard liquor like,
Vodka or rum? Try to include even those times
when you only drink a small amount (e.g. one
or two sips). (Please mark one circle for each line)
Every day
Every week
Every month
Rarely
Never
71
69. Have you ever had so much alcohol that you
were really drunk?
No, never
Yes, once
Yes, 2-3 times
Yes, 4-10 times
Yes, more than 10 times
a. Beer
b. Wine
c. Liquor/Spirits
d. Pre-mixed drinks (for example,
Smirnoff Ice, Bacardi Breezer,
Mike’s Hard Lemonade)
e. Any other drink that contains alcohol
70. Have you ever taken marijuana (pot, weed,
hashish, joint)? (Please mark one circle for each line)
78
66. On how many occasions (if any) have you done
the following things in the last 30 days? (Please
mark one circle for each line.)
72
None
A few
Some
Most
All
Never
Once or twice
3-5 times
6-9 times
10-19 times
20-39 times
40 times or more
Never
Once or twice
3-5 times
6-9 times
10-19 times
20-39 times
40 times or more
a. In your life
b. In the last 12 months
c. In the last 30 days
a. Smoked cigarettes
b. Drunk alcohol
c. Been drunk
10
71. Father—Does your father have a job?
No
Don’t know
Yes
Don’t have or don’t see father
73. Were you born in the United States?
Yes
No
If YES, please say in what place he works
(for example: hospital, bank, restaurant)
74. Which country was your mother born?
_
Don’t know
_____________________________________
Please write down exactly what job he does
there (for example: teacher, bus driver)
__________________________________________
_____________________________________
If NO, why does your father not have a job?
(Please mark the circle that best describes the situation)
He is sick, or retired, or a student
He is looking for a job
He takes care of others, or is full-time in the home
I don’t know
75. Which country was your father born?
_
Don’t know
__________________________________________
76. What language do you most often speak at
home?
72. MOTHER—Does your mother have a job?
No
Don’t know
Yes
Don’t have or don’t see mother
__________________________________
If YES, please say in what place she works
(for example: hospital, bank, restaurant)
_____________________________________
Please write down exactly what job she does
there (for example: teacher, bus driver)
_____________________________________
If NO, why does your mother not have a job?
(Please mark the circle that best describes the situation)
She is sick, or retired, or a student
She is looking for a job
She takes care of others, or is full-time in the home
I don’t know
This is the end of the survey.
If there is time, please go back and review each question to be sure you have answered all the questions and followed the directions.
THANK YOU VERY MUCH FOR YOUR HELP!
6
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| File Type | application/pdf |
| Author | MaryAnn D'Elio |
| File Modified | 2008-08-26 |
| File Created | 2008-08-15 |