Form 1 generation Health Study Survey

OMB No.: ####-####
Expiration Date: ##/##/####

10

2009–10
Generation Health Study Survey
Public reporting burden for this collection of information is estimated to average 35 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 (####-####). Do not return the completed form to this address.

This survey asks about your health. You were selected to participate in an ongoing study of health in U.S. adolescents and
young adults. The information you give will be used to improve the health of students like you.
This survey is confidential; what you say on this survey will not be revealed to anyone else. DO NOT write your name
anywhere on this survey booklet. You will be identified by a special ID number. Your answers will be read by computer.
Answer the questions based on what you really do, think, and feel. Completing the survey is voluntary and you should
have indicated your interest in participating in this study by signing a consent form. If you DID NOT SIGN a consent form,
please return the form without completing it.
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 11, 12, 13, 34, 56, 57 and 69 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 “Mark one circle on each line” as shown here:
Example: How often do you do each of the following: (Mark one circle on each line)
Often Sometimes Never

a. Swim

b. Bowl

c. Play Tennis

4. About how many hours a day do you usually
use a DVD player or watch television (including
videos and DVDs) in your free time? (Please mark
one circle for weekdays and one circle for weekend)

1. 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
 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

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
2. Do you have a computer, games console, or
television in the room where you sleep?
 No
 Yes

Different people have different reasons for deciding
how much time they spend doing things. We want
to know how true each of these reasons is for you.

3. About how many hours a day do you usually
use a computer or cell phone for chatting
on-line, internet, emailing, tweeting or for
something similar (other than school work)
during your free time? (Please mark one circle for
weekdays and one circle for weekend)

5. The amount of free time I spend watching TV
and videos, playing video games, and using
computers is because: (Please mark one circle for
each line on a scale from 1 to 7 where 1 means Not
at all True and 7 means Very True.)

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

Not at
all true
1

a. It is a choice I 
really want to
make for myself
b. I enjoy it

c. It is something 
my friends
approve of
d. I feel pressured 
to do it
e. It is personally 
important to
me
f. I have the

opportunity
or it is part of
how my day is
structured

2

Somewhat
True
2

3

4

Very
True
5

6

7

     
     
     
     
     
     

6. How many computers does your family own?
 None  Two
 One  More than two
7. Do you have your own bedroom for
yourself?
 No
 Yes

Children
Please write how many brothers and sisters live here
(including half, step or foster brothers and sisters).

8. Does your family own a car, van or truck?
 No
 Yes, one
 Yes, two or more

Please write in the number or write 0 (zero) if there
are none.
How many
brothers? __________

9. 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

How many
sisters? ___________

13. Do you have another home or another family,
such as the case when your parents are
separated or divorced?
 No - GO TO QUESTION 14
 Yes

How often do you stay there?

 Half the time

 Regularly but less than half the time

 At weekends

 Sometimes

 Hardly ever

10. What do you consider your ethnicity to be?
 Hispanic or Latino  Not Hispanic or Latino
11. 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

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
____________________________________

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.

12. Please answer this question for the home
where you live all or most of the time and 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
____________________________________

Children
Please write 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? __________

3

How many
sisters? ___________

14. Do you think your body is…?
 Much too thin
 A bit too thin
 About the right size
 A bit too fat
 Much too fat

Vigorous physical activity is any activity that
increases your heart rate and makes you get out of
breath some of the time.
For the next two questions, add up all the time you
spent in vigorous physical activity each day.

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.

16. How OFTEN do you usually engage in vigorous
physical activity 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

For this next question, add up all the time you
spent in physical activity each day.
15. 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

17. How many HOURS a week do you usually
engage in vigorous physical activity 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
18. Think about the last seven days. How often did
you do each of these when making plans for
vigorous physical activity? (Please mark one circle
for each line)
21

Very often
Often
Sometimes
Seldom
Not at all

a. I planned when to exercise
b. I planned how often to exercise
c. I planned where to exercise

4

23. On a typical day is the MAIN part of your journey
FROM school made by…? (Please mark one circle only)
 Walking
 Bicycle
 Bus, train, subway, metro, streetcar, or boat
 Car, motorcycle, moped or motorized scooter
 Other means

19. In the past week, how many times did you
take a walk outside including walking the
dog and walks for exercise? (Please write in the
number of times)

WALKS OUTSIDE _______
 Don’t know

And in the past week, how much total time did
you spend walking? Please write in the number. For
example, if you walked for a total of 1 hour and 45
minutes in the past week you would enter:
HOURS
1
MINUTES
45

HOURS
 Don’t know

Different people have different reasons for deciding
whether or not to do things. We want to know how
true each of these reasons is for you.

MINUTES
24. When I am physically active for at least one
hour it is because: (Please mark one circle for each
line on a scale from 1 to 7 where 1 means Not at all
True and 7 means Very True.)

20. In the past week, how many times did you
ride a bicycle outside including bicycling for
exercise? (Please write in the number of times)

Not at
all true

BIKE RIDES _______
 Don’t know

And in the past week, how much total time did
you spend biking? Please write in the number. For
example, if you biked for a total of 1 hour and 45
minutes in the past week you would enter:
HOURS
1
MINUTES
45

HOURS
 Don’t know

1

a. It is a choice I 
really want to
make for myself
b. I enjoy it

c. My parents, 
other family
members, or
friends tell me
to do it
d. I feel pressured 
to do it
e. It is personally 
important to
me
f. I am required 
to do it

MINUTES

21. 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
22. On a typical day is the MAIN part of your journey
TO school made by…? (Please mark one circle only)
 Walking
 Bicycle
 Bus, train, subway, metro, streetcar, or boat
 Car, motorcycle, moped, or motorized scooter
 Other means

Somewhat
True
2

3

4

Very
True
5

6

7

     
     
     

     
     
     

25. On days that you go to school, work, or similar
activities, what time do you usually wake up?
_____hour, ______minute, AM / PM
On those days, what time do you usually go to
sleep the night or day before?
_____hour, ______minute, AM / PM

5

26. On days that you don’t have to get up at a
certain time, what time do you usually wake up?

This question asks about food you ate or drank
during the past 7 days. Think about all the meals
and snacks you had from the time you got up until
you went to bed. Be sure to include food you ate at
home, at school, at restaurants, or anywhere else.

_____hour, ______minute, AM / PM
On those days, what time do you usually go to
sleep the night or day before?
_____hour, ______minute, AM / PM
27. Over the past four weeks:

30. During the past 7 days, how many times did
you...? (Please mark one circle for each line)

How often did you have trouble falling asleep?
(Please mark one circle only)
 Never in the past 4 weeks

Less than once a week

1 or 2 times a week

3 or 4 times a week

5 or more times a week

31

How often did you have trouble staying asleep
through the night? For example, you woke up
several times at night or woke up earlier than
you planned to? (Please mark one circle only)
 Never in the past 4 weeks

Less than once a week

1 or 2 times a week

3 or 4 times a week

5 or more times a week

4 or more times per day
3 times per day
2 times per day
1 time per day
4 to 6 times
1 to 3 times
Never

a. Drink 100% fruit juices such
as orange juice, apple juice, or
grape juice? (Do not count
punch, Kool-Aid, sports drinks,
or other fruit-flavored drinks.)
b. Eat fruit? (Do not count fruit
juice.)

28. Based on what you have noticed or what others
have told you, are there times when you snore
or you stop breathing during your sleep?
 Yes
 No

c. Eat green salad?

29. 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)

e. Eat carrots?

d. Eat potatoes? (Do not count
french fries, fried potatoes, or
potato chips.)
f. Eat other vegetables? (Do not
count green salad, potatoes, or
carrots.)

Weekdays
Weekend
0
 I never have
 I never have breakfast
breakfast during during the weekend
weekdays
 I usually have breakfast
 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)

g. Drink a can, bottle, or glass of
soda or pop, such as Coke,
Pepsi, or Sprite? (Do not
include diet soda or diet pop.)
h. Drink a glass of milk? (Include
the milk you drank in a glass or
cup, from a carton, or with
cereal. Count the half pint of
milk served at school as equal
to one glass.)

6

33. 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

Different people have different reasons for deciding
whether or not to do things. We want to know how
true each of these reasons is for you.
31. I eat the way I do most days because: (Please
mark one circle for each line on a scale from 1 to 7 where
1 means Not at all True and 7 means Very True.)
Not at
all true
1

a. It is a choice I 
really want to
make for myself
b. It makes me 
feel good
c. It is influenced 
by whether
other people
would be mad
at me
d. I feel pressured 
to
e. It is personally 
important to
me
f. It is what is

easily available
to eat

Somewhat
True
2

3

4

Very
True
5

6

34. Where do you usually eat your hot meal on
schooldays? (If you eat 2 hot meals a day, you may
mark 2 circles)
 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 hot meal

7

     
     
     

35. How often do you eat a snack while you...?

     

35

     
     

a. Watch TV (including videos and
DVDs)?
b. Work or play on a computer or
games console?

32. (Please mark one circle for each line)
32

Every day
5-6 days a week
3-4 days a week
1-2 days a week
Less than once a week
Never

Every day
5-6 days a week
3-4 days a week
1-2 days a week
Less than once a week
Never

36. 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

a. How often do you have breakfast
together with your mother (or
stepmother) or father
(or stepfather)?
b. How often do you have an
evening meal together with your
mother (or stepmother) or father
(or stepfather)?

37. When did you last weigh yourself?
 Within the last week
 Within the last month
 Within the last 6 months
 More than 6 months ago

c. How often do you watch
television during a meal at home?
d. How often do you have a meal
with friends outside of school?
7

38. 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. 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

39. How much do you weigh without clothes? (In
pounds)
If you don’t know how much you weigh (within
a few pounds), mark this circle 
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
 4
 5
 6
 7
 8
 9

 0
 1
 2
 3

42. Would you say your health is...? (Please mark
one circle)
 Excellent
 Fair
 Good
 Poor
43. 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

 0
 1
 2
 3
 4
 5
 6
 7
 8
 9

44. In the last 6 months: how often have you had the
following…? (Please mark one circle for each line)
44

40. How tall are you without shoes?
If you don’t know how tall you are (within an
inch or two), mark this circle 

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

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

Rarely or never
About every month
About every week
More than once a week
About every day

45. 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. Something else

If yes, what?____________________________

8

46. 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?
 Yes. If yes, please write what they are.

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)

_________________________________________
 No
47. 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
If yes, please write what it is:___________________

a. Father
b. Stepfather (or mother’s boyfriend)
c. Mother
d. Stepmother (or father’s girlfriend)
e. Brother(s) or sister(s)
51. How much does your mother (or female
guardian) really know about…? (Please mark one
circle for each line)

48. 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

51

Don’t have/see mother/guardian
She doesn’t know anything
She knows a little
She knows a lot

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

49. Think about how you have been feeling over the
last 30 days. How often...? (Please mark one circle
for each line)
49

Don’t have or see this person
Very difficult
Difficult
Easy
Very easy

50

Always
Often
Sometimes
Seldom
Never

52. How much does your father (or male guardian)
really know about…? (Please mark one circle for
each line)
Don’t have/see father/guardian
He doesn’t know anything
51
He knows a little
He knows a lot

a. Were you very sad?
b. Were you grouchy or irritable, or in
a bad mood?
c. Did you feel hopeless about the
future?
d. Did you feel like not eating or
eating more than usual?
e. Did you sleep a lot more or a lot less
than usual?
f. Did you have difficulty
concentrating on your school work?

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

9

53. How often do your parents/guardians encourage
you to…… (Please mark one circle for each line on a
scale from 1 to 7 where 1 means Rarely/never and
7 means Frequently.)
Rarely/
Never
1

a. Get daily

physical
activity and/or
exercise?
b. Eat a healthful 
diet (including
fruits & vege tables, and
limiting junk
food, sweets &
fatty foods)?
c. Limit your time 
watching TV
and videos,
playing video
games, or using
the computer?
d. Not use

alcohol
e. Not smoke

cigarettes
f. Not use

marijuana
g. Not physically 
hurt or threat en to hurt a
romantic
partner
h. Not swear at, 
insult, call
names, and/or
treat disrespect fully a roman-
tic partner

Occasionally
2

3

4

54. How important is it to your parents/guardians
that you … (Please mark one circle for each line on
a scale from 1 to 7 where 1 means Not at all and 7
means Extremely.)

Frequently
5

6

Not at all
1

7

a. Get daily

physical
activity and/or
exercise?
b. Eat a healthful 
diet (including
fruits & vege tables, and
limiting junk
food, sweets &
fatty foods)?
c. Limit your time 
watching TV
and videos,
playing video
games, or using
the computer?
d. Not use

alcohol
e. Not smoke

cigarettes
f. Not use

marijuana
g. Not physically 
hurt or threat en to hurt a
romantic
partner
h. Not swear at, 
insult, call
names, and/or
treat disrespect fully a roman-
tic partner

     

     

     

     
     
     
     

     

Somewhat
2

3

4

Extremely
5

6

7

     

     

     

     
     
     
     

     

55. Your group of friends is well accepted by your
parents?
 Almost always

Sometimes

Never, almost never

They haven’t met your group of friends

10

56. Continued...
Please re-enter the same names and grades:

56. Think of your closest male friends. List up to
five of your closest male friends. List your best
male friend first, then your next best friend,
and so on. Include boys who are friends and
boyfriends.

Their initial, first
name or nick name
What grade are
they in?
Please mark the circle
under the name if:
a. You went to his
house in the last
seven days when a
parent was present.

Their initial, first
name or nick name

What grade are
they in?

Please mark the circle
under the name if:

k. You are linked
through his online
network profile
(‘friend’ on Face-
book, ‘follower’ on
Twitter).
l. You exercised or
played sports with
him in the last seven
days.

b. You went to his
house in the last
seven days without
a parent present.

m. You ate a meal with
him in the last
seven days.

c. He came to your
house in the last
seven days when a
parent was present.

n. You played com puter games with
him in the last seven
days.

d. He came to your
house in the last
seven days without
a parent present.

o. You watched
television or videos/
DVDs with him in the
last 7 days.

e. You met him after
school to hang out
or go somewhere in
the last seven days.
f. You spent time with
him last weekend.

p. You smoked with
him in the last 30
days.

g. You talked with him
about a problem in
the last seven days.

q. You drank alcohol
with him in the
last 30 days.

h. You talked with him
on the telephone in
the last seven days.

r. You got drunk with
him in the last 30
days.

i.

You emailed, text
messaged, or
twittered him in the
last seven days.

j. He is linked through
your online network
profile (‘friend’ on
Facebook, ‘follower’
on Twitter).
11

57. Think of your closest female friends. List up
to five of your closest female friends. List your
best female friend first, then your next best
friend, and so on. Include girls who are friends
and girlfriends.

57. Continued...
Please re-enter the same names and grades:

Their initial, first
name or nick name
What grade are
they in?
Please mark the circle
under the name if:
k. You are linked
through her online
network profile
(‘friend’ on Face-
book, ‘follower’ on
Twitter).

Their initial, first
name or nick name
What grade are
they in?
Please mark the circle
under the name if:

a. You went to her
house in the last
seven days when a
parent was present.

l. You exercised or
played sports with
her in the last seven
days.

b. You went to her
house in the last
seven days without
a parent present.

m. You ate a meal with
her in the last
seven days.

c. She came to your
house in the last
seven days when a
parent was present.

n. You played com puter games with
her in the last seven
days.

d. She came to your
house in the last
seven days without
a parent present.

o. You watched
television or videos/
DVDs with her in the
last 7 days.

e. You met her after
school to hang out
or go somewhere in
the last seven days.

p. You smoked with
her in the last 30
days.

f. You spent time with
her last weekend.

q. You drank alcohol
with her in the
last 30 days.

g. You talked with her
about a problem in
the last seven days.

r. You got drunk with
her in the last 30
days.

h. You talked with her
on the telephone in
the last seven days.
i.

You emailed, text
messaged, or
twittered her in the
last seven days.

j. She is linked through
your online network
profile (‘friend’ on
Facebook, ‘follower’
on Twitter).
12

58. Think of your closest male friend, your closest female friend, your 5 closest friends, and the general
group of friends and classmates that you spend time with. For each answer on a five-point scale:
How often they do each of these things.

1 = never; 2 = almost never; 3 = sometimes; 4 = often; 5 = almost always

Please mark one circle per friend:

a. Get vigorous physical activity at least
3 times a week
b. Drink soda
c. Drink alcohol
d. Get drunk
e. Smoke cigarettes
f. Smoke/use marijuana
g. Take other drugs
h. Play computer games at least 2
hours every day
i. Watch TV at least 2 hours every day
j. Spend free time with you in the after-
noons or evenings hanging out
without adults around

Closest male
friend

Closest female
friend

Five closest
friends

Friends &
classmates

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

60. 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

59. 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

13

Now we are going to ask you questions about
romantic relationship partners. If you have never
had a boyfriend or girlfriend, or a romantic
relationship, please skip to question 62.

Different people have different reasons for deciding
whether or not to do things. We want to know how
true each of these reasons is for you.
(For the next two (2) questions, please mark one circle
for each line on a scale from 1 to 7 where 1 means
Not at all True and 7 means Very True.)

61. During any of your romantic relationships in
the last 12 months, did any of your boyfriends/
girlfriends do any of the following:

Don’t
Yes No know

62. If I ever physically hurt or threaten to hurt a
romantic partner it is or would be because:

a. Did he/she call you names,
insult you, or treat you disre-
spectfully in front of others?

Not at
all true
1

a. It is a choice I 
really want to
make for
myself
b. It makes me 
feel good
c. My friends will 
like me better
d. I feel pressured 
to
e. It is personally 
important to me
f. My partner lets 
me

b. Did he/she swear at you?
c. Did he/she threaten you with
violence?
d. Did he/she push or shove
you?
e. Did he/she throw something
at you that could hurt you?
61b.During any of your romantic relationships
in the last 12 months, did you do any of the
following to any of your boyfriends/girlfriends:

Don’t
Yes No know

a. Did you call him/her names,
insult them, or treat them dis-
respectfully in front of others?

Somewhat
True
2

3

4

Very
True
5

6

7

     

     
     
     
     
     

63. If I ever swear at, call names, insult, and/or
treat disrespectfully a romantic partner it is or
would be because:

b. Did you swear at him/her?

Not at
all true

c. Did you threaten him/her
with violence?

1

a. It is a choice I 
really want to
make for
myself
b. It makes me 
feel good
c. My friends will 
like me better
d. I feel pressured 
to
e. It is personally 
important to me
f. My partner lets 
me

d. Did you push or shove
him/her?
e. Did you throw something
at him/her that could hurt
him/her?

14

Somewhat
True
2

3

4

Very
True
5

6

7

     

     
     
     
     
     

64. At present, how often do you drink anything alcoholic,
such as beer, wine, or hard liquor like vodka or rum?
Throughout these questions, by a “drink,” we mean a
can or bottle of beer, a glass of wine or a wine cooler,
a shot of liquor, or a mixed drink with liquor in it.
Please do not include any time when you only had a
sip or two from a drink. (Please mark one circle for each line)

67. Think back again over the LAST 30 DAYS. If
you are a boy, how many times (if any) have
you had five or more drinks in a row on an
occasion? If you are a girl, how many times (if
any) have you had four or more drinks in a row
on an occasion.
 None

1

2

3-5

6-9

10 or more times

Never
Rarely
Every month
Every week
Every day

44

68. Think back again over the LAST 30 DAYS. If you
are a boy, how many times (if any) have you
had five or more drinks in a row within two
hours? If you are a girl, how many times (if
any) have you had four or more drinks in a row
within two hours?
 None

1

2

3–5

6–9

10 or more 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
65. Think about the first time you had a drink of an
alcoholic beverage. How old were you the first
time you had a drink of an alcoholic beverage?
Please do not include any time when you only
had a sip or two from a drink. (If there is something
you have not done, choose the ‘never’ category)

a. Drink alcohol
(more than a
small amount)

69. Think of the last time you drank alcohol. Where
were you when you drank? (Please mark all that
apply)

I never drink alcohol
 At home
 At someone else’s home
 Out on the street, in a park, beach or other open
area
 At a bar or a pub
 In a club
 In a restaurant
 Other places (please describe)
________________________________________

 Never I was _____ years old

(write in blank how
old you were)

b. Drink 5 or more  Never I was _____ years old
(write in blank how
drinks on a
old you were)
single occasion
c. Get drunk

 Never I was _____ years old

(write in blank how
old you were)

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)
61

40 times or more
20-39 times
10-19 times
6-9 times
3-5 times
Once or twice
Never

a. Smoked cigarettes
b. Drunk alcohol
c. Been drunk
15

72. I decide whether or not to smoke marijuana
because:
Not at
Somewhat
Very
True
True
all true

Different people have different reasons for deciding
whether or not to do things. We want to know how
true each of these reasons is for you.

1

a. It is a choice I 
really want to
make for
myself
b. It makes me 
feel good
c. My friends will 
like me better
d. I feel pressured 
to
e. It is personally 
important to me
f. It depends on 
how easily I
can get it

For the next three (3) questions, please mark one
circle for each line on a scale from 1 to 7 where 1
means Not at all True and 7 means Very True.

70. I decide whether or not to smoke tobacco
because:
Not at
Somewhat
True
all true
1

a. It is a choice I 
really want to
make for
myself
b. It makes me 
feel good
c. My friends will 
like me better
d. I feel pressured 
to
e. It is personally 
important to me
f. It depends on 
how easily I
can get it

2

3

4

5

6

a. It is a choice I 
really want to
make for
myself
b. It makes me 
feel good
c. My friends will 
like me better
d. I feel pressured 
to
e. It is personally 
important to me
f. It depends on 
how easily I
can get it

7

     

     

3

4

5

6

7

     

     
     
     
     
     

     
73. Have you ever taken one or several of these
drugs in the last 12 months? (Please mark one
circle for each line)
40 times or more
20-39 times
66
10-19 times
6-9 times
3-5 times
Once or twice
Never

     
     
     

a. Marijuana

71. I decide whether or not to drink alcohol
because:
Not at
Somewhat
True
all true
1

Very
True

2

2

3

4

5

b. Ecstasy

Very
True
6

c. Amphetamines (meth, ice,
glass, speed)

7

     

d. Opiates (heroin, morphine,
smack)
e. Medication to get high

     

f. Cocaine

     

h. Baltok

g. Glue or solvents
i. LSD

     

j. Anabolic steroids

     

k. Other drug. Which one?
___________________________

     

16

80. On how many days in the past month have
you done the following while driving?

74. Do you have a driver’s license?
 No license [skip to Question 82]
 Learner’s permit [skip to Question 82]
 Provisional license to drive with adult
supervision

Full license allowing independent, unsupervised
driving

a. Exceeded the speed limit in residential or
school zones?

b. Gone 10 -19 miles per hour over the speed
limit?
______
c. Gone 20 or more miles per hour over the
speed limit?
______
d. Purposely tailgated or followed another
vehicle very closely?
______
e. Switched lanes to weave through slower
traffic?
______
f. Changed lanes with very little room
between vehicles?
______
g. Cut in front of a vehicle to turn?
______

75. How much of the time during the past 30 days
have you had access to a vehicle?
 None
 Some
 Most

All

For questions 76, 78, 79 and 80, please fill in the
number of days from 0 to 30. For question 77,
please fill in the number of miles in whole numbers.
76. On how many of the last 30 days did you
drive a vehicle?
______
77. On average, about how many miles
did you drive each day you drove?
78. On how many days in the past month
have you driven with 2 or more
passengers in the vehicle?

______

______

79. On how many days in the past month
have you done the following while driving?

a. Taken incoming call from wireless phone ______
b. Made outgoing call from wireless phone ______
c. Changed radio station

g. Drank or eaten

______
______

h. Used a navigation system

______

h. Pulled out into traffic without waiting for
a large space between vehicles?

______

i. Made an illegal U-turn?

______

j. Gone through an intersection when the
light was yellow or just turning yellow?

______

k. Gone through an intersection when the
light was red or just turning red?

______

l. Gone through a stop sign without
stopping completely?

______

m. Changed lanes without signaling?

______

n. Playing the radio very loudly?

______

o. Raced another vehicle, even just for a
short distance?

______

p. Reading, grooming, or engaging in
similar activities?

______

q. Drove in a way to show off to other

______

d. Changed music on an MP3, CD or other device ______
e. Read text messages
______
f. Sent text messages

______

i. Looked at maps or directions while driving ______

people?

______

r. Not wear a seat belt?

______

s. Drove when sleepy or drowsy?

______

t. Drove after midnight

______

u. Drove after drinking alcohol or using
illegal drugs?

______

81. During the past year, how many times did you
drive a car or other vehicle when you had been
drinking alcohol?
 0 times
 1 time
 2 or 3 times

4 or 5 times

6 or more times

17

82. How often do you wear a seat belt when riding
in a vehicle driven by someone else?
 Never
 Rarely

Sometimes

Most of the time

Always

87. What kept you from seeing a health
professional when you really needed to?
 Didn’t know whom to go see
 Had no transportation
 No one available to go along
 Parent or guardian would not go
 Didn’t want parents to know
 Difficult to make appointment
 Afraid of what the doctor would say or do
 Thought the problem would go away
 Couldn’t pay
 Other________________________________

83. During the past year, how many times did you
ride in a car or other vehicle driven by someone
who had been drinking alcohol?
 0 times
 1 time
 2 or 3 times

4 or 5 times

6 or more times

88. In the past 12 months, did a health problem get
worse because you did not get care when you
thought you should?
 Yes
 No

84. In the last year, have you been involved in a
motor vehicle accident?

Yes

No

If so, was anyone injured when you were riding
in a car driven by someone who had been
drinking alcohol?

Yes

No

Was anyone injured when you were driving a
car when you had been drinking alcohol?

Yes

No

89. Where do you usually go when you are sick or
need health care?
 Never get sick or need health care
 Hospital-based clinic
 Hospital emergency room
 Community health center or clinic
 Health maintenance organization (HMO)
 Private doctor’s office
 School or college clinic
 Military hospital or clinic
 Clinic at work
 Some other place
90. How long ago did you last have a routine checkup?
 Within the past 3 months
 4 to 6 months ago
 7 to 9 months ago
 10 to 12 months ago
 Longer than 1 year ago but less than 2 years ago
 2 years ago or longer
 Never

85. Which of the following best describes your
current health insurance situation?
 You have no health insurance
 You are covered by your parent’s insurance
 You get insurance through school
 You buy private insurance yourself
 You get insurance through work
 You are on Medicaid
 You are covered through the Indian Health
Service
 You do not know what your health insurance is
 Other ________________________________
86. Has there been any time in the past 12 months
when you thought you should get medical care,
but you did not?
 Yes
 No
(if yes go to 87, if no skip to 88)

18

91. At your last physical examination by a doctor or
nurse...
a. Were you asked:
–whether you drink alcohol?

Yes 
No
–whether you smoke?

Yes  No
–whether you use drugs?

Yes  No
–whether you exercise?

Yes  No
–nutrition questions?

Yes  No

b. Were you given advice about
the risks associated with
–drinking?
–smoking?
–using drugs?
–not exercising?
–a poor diet?


Yes

Yes

Yes

Yes

Yes

c. Were you given advice about
–reducing or stopping drinking? 
Yes
–reducing or stopping smoking? 
Yes
–reducing or stopping using
–drugs?

Yes
–increasing physical activity?

Yes
–improving your diet?

Yes

97. Where were your grandparents born?
 All in the United States
 Some of them in the United States
 None of them in the United States
98. In your home, do you speak…
 Only English
 Mostly English
 English and another language equally
 Mostly another language
 Only another language

 No
 No
 No
 No
 No

99. With your friends, do you speak…
 Only English
 Mostly English
 English and another language equally
 Mostly another language
 Only another language

 No
 No

100.Father—Does your father have a job?
 No
 Don’t know
 Yes
 Don’t have or don’t see father

 No
 No
 No

If YES, please say in what place he works
(for example: hospital, bank, restaurant)

92. In the past 12 months have you had a dental
examination by a dentist or dental hygienist?
 Yes  No

_____________________________________
Please write down exactly what job he does
there (for example: teacher, bus driver)

If no, how long ago did you last have a dental
examination by a dentist or hygienist?
 Longer than 1 year ago but less than 2 years ago
 2 years ago or longer
 Never

_____________________________________
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

93. In what country were you born?


United States
 Other____________________________

101.MOTHER—Does your mother have a job?
 No
 Don’t know
 Yes
 Don’t have or don’t see mother

94. How old were you when you first moved to the
United States?
 I was born in the United States
 Less than 1 year old
 1-5 years old
 6-10 years old
 11-15 years old
 16 years old or older
 I don’t know
95. Where was your mother born?
 United States  Other

 I don’t know

96. Where was your father born?
 United States  Other

 I don’t know

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

19

NEXT Survey Administration Guide
Step 1 - Using the classroom roster, verify with the teacher that all
assembled students have parental permission. Do this before the class
session starts.
Step 2 – Be sure the students are seated and their desks are cleared of
papers. Ask students to spread out desks if necessary. DO NOT
distribute any materials, including the survey booklets.
Step 3- Team should distribute survey booklets, envelopes and pencils
by calling student names. Have at least two members of the team call
names and distribute materials.
Step 4 – Team Leader should introduce the survey to the class.
Good (Morning/ Afternoon). My name is _________________ and I’d like
to thank each of you for agreeing to participate in the NEXT Generation
Health Study. I’d also like to introduce _______ and ______ who will be
working with you today. The purpose of this study is to learn more about
things that affect your health. We are working with thousands of young
people throughout the U.S. The information you give will be used to
develop programs for young people like yourself and provide better health
services.
It is important to know that your answers will be kept private and will not
be seen by your parents or teachers. Also, to protect your privacy, please
DO NOT write your name anywhere on the survey booklet, either.
This is not a test -- there are no “right or wrong” answers. Answer the
questions based on what you really do, think, and feel. You do not have to
answer any questions that make you feel uncomfortable. Whether or not

1

you answer the questions will not affect your grade in this class. Please, do
not talk to each other until everyone has finished.

Let’s go over the instructions on the first page of the Survey. [Read aloud
only the bulleted instructions on cover. After reading instructions, say:].
When you are finished, look over your survey booklet to make sure that
you haven’t skipped any questions. Raise your hand and let us know
when you are done. We will ask you to bring your completed survey to us.
We will quickly check to see if you missed a question or perhaps filled in
two circles on the same question by mistake. Then you will put the survey
in the envelope, seal it, and place it in this Federal Express Pak. When
everyone is done, I will seal the Pak and send it to our office in
Washington, D.C.
Are there any questions? Turn to page 2 and begin.
Step 5 – Check each survey for completeness.
• If a question is skipped, ask the student if the question was
skipped on purpose. If not, give student the opportunity to
complete.
• If more than one circle is filled in, ask student to pick one answer.
• Make sure HEIGHT and WEIGHT is entered correctly.
• Make sure the student has not written a name anywhere on the
survey booklet or envelope.
• Have student seal the survey in envelope and place in the FedEx
Pak.
• Thank the student.
• Ask student to return to seat and remain quiet until all are students
are completed.
Step 6 – Thank class for participating. Thank teacher for help. Continue
with plan to complete height, weight, and waist circumference
measurements.
2