Attachment 6
Data Collection Instrument
Form Approved
OMB NO: 0920-0604
Exp. Date: 01/31/2010
Centers for Disease Control and Prevention
National Center for Injury Prevention and Control
Division of Violence Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Adolescent and School Health
National Institute of Justice
U.S. Department of Education
School Associated Violent Deaths in the United States
Data Collection Instrument
Public reporting burden of this collection of information is estimated at 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-0604).
INSTRUCTIONS:
Investigators should record their investigator number in space provided.
Before beginning the interview, be certain to read the telephone script that explains the study and contains the statement of informed consent. DO NOT RECORD ANY IDENTIFYING INFORMATION.
Record the preassigned Event Number in the space provided.
Instructions for the investigator are written in italics, this information should not be read to the respondents.
Information written in bold face is to be read to the respondent, unless specifically stated otherwise.
Date of data collection (code four-digit years) _ _/_ _/_ _ _ _
Investigator Identifier Code _ _
Case ID Number _ _ _ _ _
General Questions
G01. How many individuals are providing information for this interview?
Indicate actual number _ _
G02. What is (are) your current position(s) in this school/district?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) principal _
b) teacher _
c) counselor _
d) superintendent _
e) school support staff _ (specify........................................................................... )
f) police official _
g) other _ (specify .................................................................................. )
G03. What was (were) your position(s) during the period in which this event took place?
Do NOT read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) principal _
b) teacher _
c) counselor _
d) superintendent _
e) school support staff _ (specify ........................................................................... )
f) police official _
g) other _ (specify .................................................................................. )
QUESTIONS about the school
Case ID. To be assigned by study coordinator, record 5-digit number
_ _ _ _ _
S01. Is the school associated with this death a public, private or charter school?
Do NOT read options
1=public
2=private
3=charter
8=unknown
9=refused to answer
_
S02. Is the school associated with this death an alternative school?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
There is no Question S03 or S04.
S05. Has there ever been another violent death associated with this school?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
S06. What grade levels are served by this school?
Write K thru 12...to be coded later
___________________________________
There are no Questions S07 to S14.
S15. What is the school's average daily attendance rate?
____________________________________
There are no questions S16 or S17
S18. How many students, if any, withdrew from school in the month following the death?
to be coded later
_______________________
S19. Does the school currently use any of the following security measures?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) walk through metal detectors _
b) hand held metal detectors _
c) armed police or security guards _
d) unarmed security guards _
e) locker searches _
f) ban on book bags and back packs _
g) no lockers issued _
h) hall monitors _
i) other (specify..............................................................................................)
S20. Does the school currently have a violence prevention curriculum and is it required?
Read options
1= yes, there is a REQUIRED curriculum
2= yes, there is an ELECTIVE curriculum
3= no such instruction*
7= not applicable*
8=unknown*
9=refused to answer*
_
*Go to Question #S25, page S4 ...Otherwise, proceed with Question #S21a.
S21a. Is the curriculum used a commercially available product?
Do NOT read options
1=yes (specify product name.............................................................................)
2=no
7=not applicable
8=unknown
9=refused to answer
_
S21. Is the violence prevention curriculum taught separately or as part of another course?
Do NOT read options
1=a separate course
2=part of another course (specify course............................................................. )
7=not applicable
8=unknown
9=refused to answer
_
S22a. How long has the violence prevention curriculum been in place?
Do NOT read options
1=less than one year
2=one to five years
3=greater than five years
7=not applicable
8=unknown
9=refused to answer
_
S22. How many students are exposed to the violence prevention curriculum each academic year?
To be coded later
_____________________
S23. For those student who participate, what is the total number of violence prevention course hours or class periods provided in one school year?
To be coded later
_____________________
S24. Which of the following components does the violence prevention curriculum include?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) how to avoid conflicts _
b) how to manage anger _
c) how to settle conflicts without physical fighting _
d) how to handle stress in healthy ways _
e) risks associated with physical fighting _
f) risks associated with carrying and using weapons _
g) risks associated with gang activities _
h) what to do if someone is thinking about suicide _
i) statistics on adolescent deaths from violence and suicide _
j) social norms on violence-related risk behaviors _ (specify.....................................................)
(PROBE: norms=socially accepted attitudes)
k) other components _ (specify.............................................................................................)
S25. Were any of the following security measures operating at the time of this event?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) walk through metal detectors _
b) hand held metal detectors ___
c) armed police or security guards _
d) unarmed security guards _
e) locker searches _
f) ban on book bags and back packs _
g) no lockers issued _
h) hall monitors _
i) other (specify..............................................................................................)
S26a. Did the school have a violence prevention curriculum in place at the time of this event?
Do NOT read options
1=yes (specify.............................................................................)
2=no
7=not applicable
8=unknown
9=refused to answer
_
S27. What actions did the school take in response to the death.
(PROBE FOR: immediate, long-term, policy, environmental, social, curricular)
to be coded later, please note sources
......................................................................................................................................................................................................................................................................................................................................
Sw01. How many incidents of student weapon carrying were identified by school staff during the year in which the incident took place?
00-##=actual number
77=not applicable
88=unknown
99=refused to answer
_ _
Sw02. How many weapons were confiscated from students during the school year in which the incident took place? (Please indicate the number of each type of weapon confiscated)
Read options
a) Handguns ___
b) Long guns ___
c) Knives, razors, box cutters, or other blades ___
d) Mace, pepper spray ___
e) Other (specify ____________)
Sw03. At the time the incident took place, did the school have an official policy regarding student weapon carrying?
Do not read options
1=yes*
2=no**
7=not applicable
8=unknown
9=refused to answer
_
*If yes, proceed with Question Sw04; then skip to Question S28, page S6
**If no, skip to Question Sw05, then proceed to Question S28, page S6.
Sw04. Please describe what actions the policy stipulated should be taken by the school when a student was identified with a weapon while under the supervision of the school?
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Sw05. If no, please describe what actions were typically taken by the school when a student was identified with a weapon while under the supervision of the school? .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
S28. How well do you know this school and its history?
Read options
1= extensive knowledge of school
2= some knowledge of school
3= little knowledge of school
4= no knowledge of school
_
QUESTIONS about the event
E01. Where did the injury event occur?
Read options
1= on school property
2= on the way to or from the campus*
3= at an off-campus school-sponsored event*
4= on the way to or from a school sponsored event*
6= other* (specify..............................................................................................)
8= unknown*
9= refused to answer
_
*If the event occurred off campus, skip to Question #E03, below .... otherwise, proceed with Question #E02
E02. Where on the campus did the injury event occur?
Read options; code written answers later; code leading zeros
01= in a classroom
02= in a hallway
03= in a cafeteria
04= in a gymnasium
05= in a locker room
06= in an office
07= on campus lawn or gardens
08= on sporting fields or playground
09= in a parking lot
10= in a driveway
66= other indoor(specify.............................................................................)
67= other outdoor (specify................................................................................)
77= not applicable
88= unknown
99= refused to answer
_ _
After completing E02, skip to Question #E04, page E2.
E03. Where did the off-campus injury event occur?
Read options; code written responses later; code leading zeros
01= on the street, sidewalk, footpath
02= on a bus or public transport vehicle
03= waiting for or alighting from bus or public transport vehicle
04= in a privately-owned vehicle
05= on private property
66= other (specify..............................................................................................)
77= not applicable
88= unknown
99= refused to answer
_ _
E04. Which of the following best describes the context in which the injury event occurred?
Read options; code written responses later; code leading zeros
01= on a day when no classes or school events were held
02= on a school day before classes began
03= while classes were being held
04= on a school day during lunch, recess or other break, including class changes
05= immediately after school
06= on a school day during after-school practice or detention
07= on a school day after official activities
08= at a school sporting activity
09= at another official school-sponsored activity
10= on the way to or from a school-sponsored activity
66= other (specify..............................................................................................)
77= not applicable
88= unknown
99= refused to answer
_ _
E05. At the time of fatal injury were any the victims in some place they ought not to have been?
Do NOT read options (PROBE: an area of restricted access)
1=yes (specify........................................................................................................... )
2=no
7=not applicable
9=unknown/refused to answer
_
E06. At the time of fatal injury were any of the offenders in some place they ought not to have been?
Do NOT read options (PROBE: an area of restricted access)
1=yes (specify........................................................................................................... )
2=no
7=not applicable
9=unknown/refused to answer
_
E07. What were the motives for the fatal injury?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) single suicide _
b) suicide pact _
c) drug related _
d) gang related _
e) robbery, attempted robbery _
f) rape, attempted sex crime _
g) dispute over money or property _
h) dispute over romantic relationship _
i) dispute related to sporting event _
j) dispute, other or unspecified _
k) racially or hate crime motivated _
l) victim killed by police or security personnel _
m) victim killed by civilian during commission of a crime _
n) random victim _
o) unintentional injury _
p) other _ (specify..............................................................................................)
E08. Briefly describe the circumstances of the fatal injury and events leading up to it, including history of prior conflicts between the principles, etc.
Code later
......................................................................................................................................................................................................................................................................................................................................
E09. What was the method of fatal injury?
Read options; code leading zeros
01= firearm (specify..............................................................)
02= knife, razor, box cutter or other blade
03= beaten with club, bat, other object
04= beaten, no weapon used
05= motor vehicle
06= hanging/strangulation
07= poisoning, solid or liquid
08= asphyxiation by gas
66= other (specify..............................................................................................)
77= not applicable
88= unknown
99= refused to answer
_ _
E10. After a tragedy such as this people look for things, such as comments, notes, threats, or actions that took place prior to the incident that could have signaled a potential risk for this type of behavior. Which of the following did any of the offenders, or victims in the case of suicide, leave as signs that they were considering this action? Please include as many signs as you can think of even if they were things that nobody could have recognized as a sign at the time they happened.
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{E10a} notes ____
{E10b} journal entry ___
{E10c} threats___
{E10d} other actions (specify.................................................................)
There is no question E11.
E12. Based on the information you have regarding the timing of precipitating factors and the amount of preparation required, how much time do you think that this offender (victim if suicide) spent planing this incident?
Do not read options; complete information for minutes, hours and days; code later
a) minutes ___
b) hours ___
c) days ___
Esc01. Did any of the following events occur during the 2 weeks before or after this incident? Please note all that apply:
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
{Esc01a} Prom/dance/social event _
{Esc01b} Graduation _
{Esc01c} Homecoming _
{Esc01d} Rivalry game between schools _
{Esc01e} Holiday break _
{Esc01f} Report card distribution _
{Esc01g} Other _ (specify __________________________)
There is no question Esc02.
_
Esc03. Was the victim cited or disciplined for disruptive behavior during the 2 weeks before the event?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
If suicide, skip to Esc05, page E5.
Esc04. Was the offender cited for disruptive behavior during the 2 weeks before the event?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
E13. How well do you know the details of this event?
Read options
1= extensive knowledge of event
2= some knowledge of event
3= little knowledge of event
4= no knowledge of event
_
QUESTIONS about the Victim
CaseID. Case ID Number
To be assigned by study coordinator, record 5-digit number
_ _ _ _ _
V01. How many victims were fatally injured in this event?
Write in actual number
_ _
V01a. Victim Number
Number for this victim, is assigned by the primary data collector.
_
V02. What was the date of the fatal injury?
Record month/date/year, code leading zeros (code four-digit years)
_ _/_ _/_ _ _ _
V03. What was the time of the fatal injury?
Record in military time
_ _ _ _
V04. What was the date of death?
Record month/date/year, code leading zeros (code four-digit years)
_ _/_ _/_ _ _ _
V05. What was the time of death?
Record in military time
_ _ _ _
V06. What was this victim's date of birth?
Record month/date/year, code leading zeros (code four-digit years)
_ _/_ _/_ _ _ _
V07. What was this victim's age in years at the time of death?
Do NOT read options, code leading zero
01-65=actual age in years
66=age 66 years and older
77=not applicable
88=unknown
99=refused to answer
_ _
V08. What was this victim's gender?
Do NOT read options
1=male
2=female
7=not applicable
8=unknown
9=refused to answer
_ _
V09. Was this victim of Latino or Hispanic origin?
Do NOT read options
1=yes
2=no
8=unknown
9=refused
_
V10. What was the victim's race?
Do NOT read Options
1=White
2=Black or African American
3=Asian
4=American Indian or Alaska Native
6=Native Hawaiian or other Pacific Islander
8=unknown
9=refused to answer
_
V11. Which of the following best describes the victim's family structure/living arrangements at the time of death?
Read options
01= two-parent nuclear family
02= single parent household
03= lives with adult relative other than parent
04= lives independently
05= foster care
06= residential institution
66= other (specify:...................)
77=not applicable
88=unknown
99=refused to answer
_ _
There is no question V12.
V13. Had the victim ever been charged with a crime before the fatal injury?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused
_
Vp01. Youth often affiliate with distinct peer groups. With which one of the following groups would you say this victim was most closely affiliated?
Read options
01= street gang
02= tagging crew (spray paint graffiti of groups logo or Atag@ around the neighborhood)
03= Wannabes (dress and act like gang members without actually belonging to a street gang)
04= Druggies or Stoners
05= Hip-Hop
06= Gothic
07= Punkers
08= Skaters/Surfers
09= Rockers
10= Cowboys/girls
11= Brains
12= Jocks, Athletes
13= Preppies
14= Geeks
15= Band
16= Hackers
17= Bible study
18= Granolas
19= Loner
20= Not a loner but no particular group
66= other (specify...........................................)
77= not applicable
88=unknown
99=refused to answer
_ _
Vp02. In the year prior to this event, was there a change in this victim’s peer group?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
V15. Did the victim use alcohol or other drugs at least once a week?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
V16. Was there evidence that the victim was intoxicated with alcohol or other drugs at the time of death?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
N.B. There is no Question V17
Vw01. During the year prior to this incident, had the victim ever been found carrying a weapon on school grounds or on the way to or from school?
Do NOT read options
1=yes
2=no*
7=not applicable*
8=unknown*
9=refused to answer*
_
*If no, Go to Question V18, page V5
Vw02. During the year prior to this incident, how many times had the victim been found carrying a weapon on school grounds or on the way to or from school?
01-##=actual number of times the victim carried a weapon
77=not applicable
88=unknown
99=refused to answer
_ _
Vw03. For the most recent event prior to the date of fatal injury, which of the following types of weapons was the victim carrying?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) rope or wire _
b) club or bat _
c) knife, razor, box cutter, or other blade _
d) firearm _ (specify.....................................................................)
e) other _ (specify........................................................................)
Vw04. What, if any, actions did the school take in response to the victim’s most recent incident of weapon carrying?
......................................................................................................................................................................................................................................................................................................................................................
V18. Was the victim carrying a weapon at the time of the fatal injury?
Do NOT read options
1=yes
2=no*
7=not applicable*
8=unknown*
9=refused to answer*
_
*If no, Go to Question #V21, page V6.
V19. At the time of the fatal injury, which of the following types of weapon was this victim carrying?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) rope or wire _
b) club or bat _
c) knife, razor, box cutter, or other blade _
d) firearm _ (specify....................)
e) other _ (specify......................)
V20. Where did this victim obtain these weapons?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) from home _ (specify weapon................................)
b) from friend or relative outside household _ (specify weapon................................)
c) purchased for himself/herself _ (specify weapon................................)
d) stolen _ (specify weapon................................)
e) from the victim (specify weapon................................)_
f) other _ (specify weapon................................)
V21. What was the highest grade or year of school this victim completed?
Do NOT read options, code leading zero
00-12=last completed grades K-12
13=high school equivalency
14=some college or trade school
15=college graduate or more
16=never attended
66=other (specify........................................................................................................)
77=not applicable
88=unknown
99=refused to answer
_ _
V22. What was the victim's affiliation with the school associated with this death?
Do NOT read options, code leading zero
01=a student at this school
02=a student at another school
03=a teacher at this school*
04=administrator at this school*
05=other staff at this school*
06=security guard or police officer*
07=family member of a student*
08=resident of surrounding community*
09=not associated with the school or community*
10=unidentified victim*
66=other* (specify.............................................................................................................)
77=not applicable*
88=unknown*
99=refused to answer*
_ _
*If the victim is NOT a student, Go to Question #V30, page V11..
V23. How many years had the victim attended his or her school?
Do NOT read options; code leading zeros
00=less than one school year
01-12=number of years
13=more than 12 years
77=not applicable
88=unknown
99=refused to answer
_ _
There is no Question V24.
V25. How many times in the last year was the victim suspended or expelled from his or her school?
Do NOT read options
0=none, never suspended
1-5=actual number of times
6=more than five times
7=not applicable
8=unknown
9=refused to answer
_
There is no question V26.
V27. What extracurricular activities was the victim involved in?
To be coded later
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Vr01. To the best of your knowledge, in the 12 months prior to this event was the victim reported to the principal=s office for any of the following behaviors?
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Vr01a} disobeying authority figure__
{Vr01b} namecalling or teasing peers __
{Vr01c} physical fighting with peers _
{Vr01d} damaging another's personal property_ _
{Vr01e} stealing another's personal property __
Vr01a. To the best of your knowledge, in the 12 months prior to this event was this individual victimized in any of the following ways?
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Vr01a} called names by peers__
{Vr01b} bullied by peers __
{Vr01c} had personal property damaged or stolen _
{Vr01d} physically threatened by peers __ _
{Vr01e} physically assaulted by peers __
Vr02. To the best of your knowledge, did the victim experience any of the following events in the last 12 months?
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Vr02a} family moved to an new home or apartment _
{Vr02b} parents divorced_
{Vr02c} family had a new baby _
{Vr02d} anyone moved out of the house _ (specify................................................)
{Vr02e} family member died ( specify...................................................................)
{Vr02f} a close relative or friend died ( specify.................................................)_
{Vr02g} family member became seriously ill, badly injured or was admitted to the hospital
(specify....................................................................)
{Vr02h} a close relative or friend beaten or attacked _ ( specify........................)
{Vr02i} saw someone beaten, attacked or shot _ ( specify ..................................)
{Vr02j} changed where they went to school _
{Vr02k} romantic breakup _
Vr03a. At the time of the event, was this victim demonstrating symptoms, such as impulsivity, short attention span, and distractibility, consistent with an Attention Deficit or a Hyperactivity Disorder?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
Vr03. At the time of the event, was the victim medically diagnosed with an Attention Deficit or a Hyperactivity Disorder?
Do not read options
1=yes
2=no*
7=not applicable
8=unknown
9=refused to answer
_
*If no, skip to Question Vr05, below.
Vr04. Was the victim being treated in any of the following ways for this problem?
Read options
1= medication alone
2= behavioral/environmental modification alone
3= both medication and behavioral/environmental modification
4= no treatment
6= other (specify..............................................................................................)
7= not applicable
8= unknown
9= refused to answer
_
Vr05. At the time of the event, did this victim have a diagnosed Learning Disability?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
Vm01. In the year prior to this event, did this victim receive school-sponsored psychological counseling services?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
Vm02. In the year prior to this event, was this victim ever treated for depression?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
Vm03a Did this victim have a documented family history of .....
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Vm03a} alcoholism _
{Vm03b} drug abuse _
{Vm03c} child abuse/neglect __
{Vm03d} intimate partner violence_
*If yes to all of the above, then skip to Vm04, below.
Vm03. To the best of your knowledge, did this victim have a suspected family history of .....
Read only those options not confirmed above, Coding instructions: 1=yes, 2=no, 8=unknown.
{Vm03a} alcoholism _
{Vm03b} drug abuse _
{Vm03c} child abuse/neglect __
{Vm03d} intimate partner violence_
Vm04. In what subject area, if any, did this victim seem to excel?
Read options in bold only
00= did not excel in any area
01= art
02= music
03= science
04= mathematics
05= social sciences
06= computer sciences
07= language arts
08= vocational/industrial arts
66= other (specify...............................)
77=not applicable
88=unknown
99=refused to answer
_ _
Vm05. In what subject areas, if any, did this victim seem to have particular difficulty?
Read options in bold only
00= did not have difficulty in any area
01= art
02= music
03= science
04= mathematics
05= social sciences
06= computer sciences
07= language arts
08= vocational/industrial arts
66= other (specify...............................)
77=not applicable
88=unknown
99=refused to answer
_ _
There is no question Vm06 or Vm07
V30. Which of the following situations best describes this victim's death?
Read options; code leading zero
01= single victim suicide*
02= multiple victim suicide*
03= single victim homicide; unknown number of offenders
04= single victim homicide; single offender
05= single victim homicide; multiple offenders
06= multiple victim homicide; unknown number of offenders
07= multiple victim homicide; single offender
08= multiple victim homicide; multiple offenders
09= combination murder/suicide
10= intention undetermined
66= other (specify........................................................................................................)
77=not applicable
88=unknown
99=refused to answer
_ _
Vs01. Do you have any knowledge that this victim had, in the year prior to this event exhibited any of the following signs and symptoms of suicide?
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Vs01a} Thoughts/threats of suicide_
{Vs01b} Plans of suicide_
{Vs01c} Previous suicide attempts_
*If no to all, skip to V31, below.
Vs02. To whom was this suicidal behavior reported?
Do not read options
01=no one
02=parents
03=other family
04=peers
05=school staff
06=other medical/mental health professional
66=other (specify...........................................)
77=not applicable
88=unknown
99=refused to answer
_ _
Vs03. What, if any, actions were taken by the school in response to this suicidal behavior?
..................................................................................................................................................................................................................................................................................................................................................................................
Vm08.What was the perceived sexual orientation of this victim?
Do not read options
1=homosexual
2=heterosexual
3=bisexual
7=not applicable
8=unknown
9=refused to answer
_
V32. How well do you know the background of this victim?
Read options
1= extensive knowledge of this victim
2= some knowledge of this victim
3= little knowledge of this victim
4= no knowledge of this victim
_
V33. How many alleged offenders were responsible for the victim's death?
Do NOT read options (PROBE: alleged offender = legally charged as offender)
0=none, death was self-inflicted
1-5=actual number of offenders*
6=more than 5*
7=not applicable
8=unknown
9=refused to answer
_
*If there is more than one victim, complete a"Victim" section for each victim, starting with Question V01...Otherwise go to Question #Vi01.
QUESTIONS about Alleged Offender
CaseID. Case ID Number
Case number is assigned by study coordinator.
_ _ _ _ _
X01. How many offenders were officially charged for this incident?
Write in actual number.
_ _
X01a. Offender Number
Number for this offender is assigned by the primary data collector.
_
There are no Questions #X02-X05.
X06. What was this offender's date of birth?
Record month/date/year, code leading zeros, code four-digit years
_ _/_ _/_ _ _ _
X07. What was this offender's age in years at time of victim's death?
Do NOT read options, code leading zero
01-65=actual age in years
66=age 66 years and older
77=not applicable
88=unknown
99=refused to answer
_ _
X08. What was this offender's gender?
Do NOT read options
1=male
2=female
7=not applicable
8=unknown
9=refused to answer
_ _
X09. Was this victim of Latino or Hispanic origin?
Do NOT read options
1=yes
2=no
8=unknown
9=refused
_
X10. What was the victim's race?
Do NOT read Options
1=White
2=Black or African American
3=Asian
4=American Indian or Alaska Native
6= Native Hawaiian or other Pacific Islander
8=unknown
9=refused to answer
_
X11. Which of the following best describes this offender's family structure or living arrangements at the time of the victim's death?
Read options
01= two-parent nuclear family
02= single parent household
03= lives with adult relative other than parent
04= lives independently
05= foster care
06= residential institution
66= other (specify:...................)
77=not applicable
88=unknown
99=refused to answer
_ _
There is no question X12
X13. Had this offender ever been charged with a crime before the victim's death?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
Xp01. Youth often affiliate with distinct peer groups. With which one of the following groups would you say the offender was most closely affiliated?
Read options
01= Member of an identified street gang
02= Member of a tagging crew (spray paint graffiti of groups logo or Atag@ around the neighborhood)
03= Wannabes (dress and act like gang members without actually belonging to a street gang)
04= Druggies or Stoners
05= Hip-Hop
06= Gothic
07= Punkers
08= Skaters/Surfers
09= Rockers
10= Cowboys/girls
11= Brains
12= Jocks, Athletes
13= Preppies
14= Geeks
15= Band
16= Hackers
17= Bible study
18= Granolas
19= Loner
20= Not a loner but no particular group
66= other (specify...........................................)
77= not applicable
88=unknown
99=refused to answer
_ _
Xp02. In the year prior to this event, was there a change in this offender’s peer group?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
X15. Did this offender use alcohol or other drugs at least once a week at the time of the victim's death?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
X16. Was there evidence that this offender was intoxicated with alcohol or other drugs at the time of the victim's death?
Do NOT read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
X17. What was the relationship of this offender to the victim?
Read options; code written responses later
01= relatives (specify..................)
02= romantic partner
03= close friend
04= casual acquaintances
05= strangers
66= other (specify......................)
77=not applicable
88=unknown
99=refused to answer
_ _
Xw01. During the year prior to this incident, had the offender ever been found carrying a weapon on school grounds or on the way to or from school?
Do NOT read options
1=yes
2=no*
7=not applicable*
8=unknown*
9=refused to answer*
_
If no, Go to Question #X18, pageO5.
Xw02. During the year prior to this incident, how many times had this offender been found carrying a weapon on school grounds or on the way to or from school?
Do NOT read options, code leading zeros
01-##=actual number of times the victim carried a weapon
77=not applicable
88=unknown
99=refused to answer
_ _
Xw03. For the most recent event prior to the date of fatal injury, was this offender carrying any of the following types of weapon?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) rope or wire _
b) club or bat _
c) knife, razor, box cutter, or other blade _
d) firearm _ (specify....................)
e) other _ (specify......................)
Xw04. What, if any, actions did the school take in response to the this offender’s most recent incident of weapon carrying?
......................................................................................................................................................................................................................................................................................................................................
X18. Was this offender carrying a weapon at the time of the fatal injury?
Do NOT read options
1=yes
2=no*
7=not applicable*
8=unknown*
9=refused to answer*
_
*Skip to Question #X21, page O6.
X19. At the time of the fatal injury, which of the following types of weapon was this offender carrying?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) rope or wire _
b) club or bat _
c) knife, razor, box cutter, or other blade _
d) firearm _ (specify....................)
e) other _ (specify......................)
X20. Where did this offender obtain these weapons?
Read options, Coding instructions: 1=yes, 2=no, 7=not applicable, 8=unknown
a) from home _ (specify weapon................................)
b) from friend or relative outside household _ (specify weapon................................)
c) purchased for himself/herself _ (specify weapon................................)
d) stolen _ (specify weapon................................)
e) from the victim (specify weapon................................)_
f) other _ (specify weapon................................)
X21. What was the highest grade or year of school this offender completed?
Do NOT read options, code leading zero
00-12=last completed grades K-12
13=high school equivalency
14=some college or trade school
15=college graduate or more
16=never attended
66=other (specify..................)
77=not applicable
88=unknown
99=refused to answer
_ _
X22. What was this offender's affiliation with the school associated with the victim's death?
Do NOT read options, code leading zero
01=a student at this school
02=a student at another school
03=a teacher at this school*
04=administrator at this school*
05=other staff at this school*
06=security guard or police officer*
07=family member of a student*
08=resident of surrounding community*
09=not associated with the school or community*
10=unidentified offender*
66=other* (specify..................)
77=not applicable
88=unknown
99=refused to answer
_ _
*If this offender is NOT a student, Go to Question Xs01, page O11 .
X23. For how many years has this offender attended his or her school?
Do NOT read options; code leading zeros
00=less than one school year
01-12=number of years
13=more than 12 years
77=not applicable
88=unknown
99=refused to answer
_ _
There is no Question X24.
X25. How many times was this offender suspended or expelled from his or her school?
Do NOT read options
0=none, never suspended or expelled
1-5=actual number of times
6=more than five times
7=not applicable
8=unknown
9=refused to answer
_
There is no Question X26.
X27. What extracurricular activities was this offender involved in at the time of the victim's death?
to be coded later; please note the sources.
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Xr01. To the best of your knowledge, in the 12 months prior to this event was this offender reported to the office for any of the following behaviors?
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Xr01a} disobeying authority figure__
{Xr01b} name calling or teasing peers _
{Xr01c} physical fighting with peers _
{Xr01d} damaging another's personal property_ _
{Xr01e} stealing another's personal property __
Xr01a. To the best of your knowledge, in the 12 months prior to this event was this offender victimized in any of the following ways?
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Xr01a} called names by peers__
{Xr01b} bullied by peers __
{Xr01c} had personal property damaged or stolen _
{Xr01d} physically threatened by peers __ _
{Xr01e} physically assaulted by peers __
Xr02. To the best of your knowledge, did this offender experience any of the following events in the last 12 months?
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Vr02a} family moved to a new home or apartment _
{Vr02b} parents divorced_
{Vr02c} family had a new baby _
{Vr02d} anyone moved out of the house ( specify..............................................)_
{Vr02e} family member died (specify....................................................)_
{Vr02f} a close relative or friend died ( specify..........................................)_
{Vr02g} family member became seriously ill, badly injured or was admitted to the hospital ( specify ………………………………………...........)_
{Vr02h} a close relative or friend beaten or attacked ( specify ........................)_
{Vr02i} saw someone beaten, attacked or shot (specify .................................)_
{Vr02j} changed where they went to school _
{Vr02k} romantic breakup _
Xr03a. At the time of the event, was this offender demonstrating symptoms, such as impulsivity, short attention span, and distractability, consistent with an Attention Deficit or a Hyperactivity Disorder? Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
Xr03. At the time of the event, was this offender medically diagnosed with an Attention Deficit or a Hyperactivity Disorder?
Do not read options
1=yes
2=no*
7=not applicable*
8=unknown*
9=refused to answer*
_
*If no, skip to Question Xr05, below.
Xr04. Were they being treated in any of the following ways for this problem?
Read options
1= medication alone
2= behavioral/environmental modification alone
3= both medication and behavioral/environmental modification
4= no treatment
7=not applicable
8=unknown
9=refused to answer
_
Xr05. At the time of the event, did this offender have a diagnosed Learning Disability?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
Xm01. In the year prior to this event, did this offender receive school-sponsored psychological counseling services?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
Xm02. In the year prior to this event, was this offender ever treated for depression?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
Xm03a Did this offender have a documented family history of .....
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Xm03a} alcoholism _
{Xm03b} drug abuse _
{Xm03c} child abuse/neglect __
{Xm03d} intimate partner violence_
*If yes to all of the above, then skip to Xm04, below
Xm03. To the best of your knowledge, did this offender have a suspected family history of .....
Read only those options not confirmed above, Coding instructions: 1=yes, 2=no, 8=unknown.
{Xm03a} alcoholism _
{Xm03b} drug abuse _
{Xm03c} child abuse/neglect __
{Xm03d} intimate partner violence_
Xm04. In what subject area, if any, did this offender seem to excel?
Read options in bold only
00= did not excel in any area
01= art
02= music
03= science
04= mathematics
05= social sciences
06= computer sciences
07= language arts
08= vocational/industrial arts
66= other (specify...............................)
77=not applicable
88=unknown
99=refused to answer
_ _
Xm05. In what subject areas, if any, did this offender seem to have particular difficulty?
Read options in bold only
00= did not have difficulty in any area
01= art
02= music
03= science
04= mathematics
05= social sciences
06= computer sciences
07= language arts
08= vocational/industrial arts
66= other (specify...............................)
77=not applicable
88=unknown
99=refused to answer
_ _
There is no question Xm06 or Xm07
Xs01. Do you have any knowledge that this offender had, in the year prior to this event exhibited any of the following signs and symptoms of suicide?
Read options, Coding instructions: 1=yes, 2=no, 8=unknown.
{Xs01a} Thoughts/threats of suicide*_
{Xs01b} Plans of suicide*_
{Xs01c} Previous suicide attempts*_
*If no to all, skip to Xm09
Xs02. To whom was this suicidal behavior reported?
Do not read options
01=no one
02=parents
03=other family
04=peers
05=school staff
06=other medical/mental health professional
66=other (specify...........................................)
77=not applicable
88=unknown
99=refused to answer
_ _
Xs03. What, if any, actions were taken by the school in response to this suicidal behavior?
To be coded later
..................................................................................................................................................................................................................................................................................................................................................................
Xm08. What was the perceived sexual orientation of this offender?
Do not read options
1=homosexual
2=heterosexual
3=bisexual
7=not applicable
8=unknown
9=refused to answer
_
Xm09. Was there evidence that this offender was targeting a specific person or group?
Do not read options
1=yes
2=no
7=not applicable
8=unknown
9=refused to answer
_
There is no question X30.
X32. How well do you know the background of this offender?
Read options
1= extensive knowledge of this offender
2= some knowledge of this offender
3= little knowledge of this offender
4= no knowledge of this offender
_
X31. Was there another offender, in addition to the one we just discussed, involved in this event?
Do NOT read options
1=yes*
2=no
7=not applicable
8=unknown
9=refused to answer
_
*If there is a second alleged offender identified as Offender Y, complete a second "Offender" section, starting with Question X01.......otherwise, conclude the interview.
| File Type | application/msword |
| File Title | Attachment 5 |
| Author | ESB1 |
| Last Modified By | ziy6 |
| File Modified | 2009-12-15 |
| File Created | 2009-12-15 |