Form 19 ATTACHMENT C20: Health Risk Behavior Survey (High School

OMB No: 0920-0747: Exp Date: ???

Health Risk Behavior Survey

HEALTH AND HEALTH RISK BEHAVIOR QUESTIONNAIRE: CHILD High School Version TABLE OF CONTENTS Injury 1 Rule Breaking 5 Tobacco/Alcohol/Drug Use 6 Physical Activity 10 Eating 12 Sleep Behavior 12 School Performance 13 Communication 13

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

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

2E. A poison related injury? Yes No 2F. A cut or pierce that required stitches? Yes No 2G. An injury caused by something like a tool or machine? Yes No 3. Do you have a drivers license or beginners permit? I do not drive I am currently learning to drive Beginners permit Conditional/restricted license Drivers license: Received Year: ________ Month_________ 4. Do you have a car of your own? I do not drive I share a car I have a car of my own 5. How frequently do you drive a car? I do not drive Daily Several times a week Once a week or less 6. During the past 30 days, how many times did you drive or ride in a car or other vehicle with more than one of your friends? 0 times 1 time 2 or 3 times 4 or 5 times 6 or more times

7. How often do you wear a seatbelt when riding in a car? Never Rarely Sometimes Most of the time Always 8. During the past year, how many of the following situations have applied to you while riding in a car with other teens or young adults? I did not ride in a car with other teens or young adults Music was loud Driver used a cell phone to talk Driver sent a text message or handled a personal electronic device Driver was angry or upset Driver was very tired Driver smoked a cigarette Driver drank alcohol or used drugs and then drove Driver put on makeup Driver was eating while driving Driver raced with others Driver broke driving rules Passengers were dancing or singing Passengers were acting wild Passengers had been drinking alcohol Passengers had used other drugs Passengers were asking driver to speed or break driving rules

If you drive, please mark how often the following has been true to you during the past year:

	I do not drive	Never	Rarely	Sometimes	Most of the time	Always
I wear my seatbelt when I drive	O	O	O	O	O	O
I drive when I feel angry or upset	O	O	O	O	O	O
I played loud music	O	O	O	O	O	O
I drive when I am very tired	O	O	O	O	O	O
I drink alcohol or use drugs and then I drive	O	O	O	O	O	O
I talk on a cell phone when I drive	O	O	O	O	O	O
I send a text message or handle a personal electronic device	O	O	O	O	O	O
I drive and smoke a cigarette	O	O	O	O	O	O
I drive more than 10 miles over the speed limit	O	O	O	O	O	O
I play loud music	O	O	O	O	O	O
I race another car	O	O	O	O	O	O
I put on makeup	O	O	O	O	O	O
I eat food while driving	O	O	O	O	O	O
Passengers were dancing or singing	O	O	O	O	O	O
Passengers were acting wild	O	O	O	O	O	O
Passengers had been drinking or using drugs	O	O	O	O	O	O
Passengers had been using drugs	O	O	O	O	O	O
Passengers asked me to speed or break driving rules	O	O	O	O	O	O

27. During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol? 0 times 1 time 2 or 3 times 4 or 5 times 6 or more times 28. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol? I do not drive 0 times 1 time 2 or 3 times 4 or 5 times 6 or more times 29. In the past 12 months, how many crashes have you been in as a driver I do not drive 0 1 2 or more 30. In your lifetime, how many crashes have you been in as a driver where someone had to see a doctor and a nurse? I do not drive 0 1 2 or more 31. In the past 12 months, how many crashes have you been in as a passenger I do not drive 0 1 2 or more 32. In your lifetime, how many crashes have you been in as a passenger where someone had to see a doctor and a nurse? I do not drive 0 1 2 or more

33. Have you ever been stopped by the police when driving? I do not drive Yes No 34. Have you ever been given a ticket for a driving violation? I do not drive Yes No 35. Do your parents have rules you must follow about driving or riding in cars (for example, where and when to drive, who may ride with you, consequences for rule-breaking, etc.)? Yes No 36. How often do you cross the street or run out into the street without checking for cars? Never Rarely Sometimes Most of the time Always 37. How often do you do dangerous things like jumping off high places? Never Rarely Sometimes Most of the time Always 38. When you ride a bicycle, how often do you wear a helmet? I do not ride a bicycle Never Rarely Sometimes Most of the time Always

39. When you roller blade or ride a skateboard, how often do you wear protective gear such as a helmet, wrist guards, or knee pads? I do not roller blade or ride a skateboard Never Rarely Sometimes Most of the time Always 40. In the past 12 months, have you carried a weapon, such as a gun, knife, or club on school property? Yes No 41. During the past 12 months, how many times were you in a physical fight? 0 times 1 time 2-3 times 4-5 times 6-7 times 8-9 times 10-11 times 12 or more times 42. During the past 12 months, how many times were you in a physical fight in which you were hurt and had to be treated by a doctor? 0 times 1 time 2 – 3 times 4-5 times 6 or more times

43. During the past 12 months, how many times were you in a physical fight on school property? 0 times 1 time 2-3 times 4-5 times 6-7 times 8-9 times 10-11 times 12 or more times 44. Have you ever tried to intentionally hurt yourself? Yes No II. Rule Breaking These next few questions are very sensitive and ask about breaking rules and laws. You can choose not to answer any of these questions. Remember these questions are private and we will not tell your parents how you answer. 45. When was the last time you stole something worth more than $50? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never 46. When was the last time you were required to appear in court for something you had done? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never

47. When was the last time you were sent to the principal or counselor for disciplinary reasons? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never 48. When was the last time you were fired from a job? Within the past month Between 1 month and 6 months Between 6 months and 1 year Over 1 year ago Never 49. If you take medication for ADHD (attention deficit/hyperactivity disorder), do you mostly take it yourself without supervision? Yes No I do not take medication for ADHD 50. If you take medication for ADHD, who tells you to take your medication? My parents always remind me Most of the time my parents remind me Most of the time I do it on my own I always remember it on my own I do not take medication for ADHD 51. If you take prescription medication for ADHD: In the past 12 months, did you ever give or sell your medication to others? Yes No I do not take medication for ADHD

52. Have you ever taken ADHD medication that was not prescribed to you by a doctor in order to study or do well on a test? Yes No III. Tobacco/Alcohol/Drug Use These next few questions are very sensitive and ask you about drug use. You can choose not to answer any of these questions. Remember these questions are private and we will not tell your parents how you answer. 53. Have you ever tried cigarette smoking, even one or two puffs? Yes No 54. How old were you when you smoked a whole cigarette for the first time? I have never smoked a whole cigarette 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15-16 years old 17 years old or older 55. Do you currently smoke on a regular basis (at least once per week)? Yes No 56. Have you ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen? Yes No

The next 5 questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes. 57. During your life, on how many days have you had at least one drink of alcohol? 0 days 1 or 2 days 3 to 9 days 10 to 19 days 20 to 39 days 40 to 99 days 100 or more days 58. How old were you when you had your first drink of alcohol other than a few sips? I have never had a drink of alcohol other than a few sips 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older 59. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours? 0 days 1 day 2 days 3-5 days 6-9 days 10-19 days 20 or more days

60. During the past 30 days, on how many days did you have at least one drink of alcohol on school property? 0 days 1 or 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days The next 4 questions ask about marijuana use. Marijuana is also called grass or pot. 61. During your life, how many times have you used marijuana? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 to 99 times 100 times or more 62. How old were you when you tried marijuana for the first time? I have never tried marijuana 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older 63. During the past 30 days, how many times did you use marijuana? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times

	64. During the past 30 days, how many times did you use marijuana on school property? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times The next 9 questions ask about other drugs. 65. During your life, how many times have you used any form of cocaine, including powder, crack, or freebase? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 66. During the past 30 days, how many times did you use any form of cocaine including powder, crack, or freebase? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 67. During your life, how many times have you sniffed glue, breathed the contents of aerosol spray cans, or inhaled any paints or sprays to get high? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 72. During your life, how many times have you used a needle to inject any illegal drug into your body? 0 times 1 time 2 or more times 73. During the past 12 months, has anyone offered, sold, or given you any illegal drug on school property? Yes No The next 7 questions ask about sexual behavior and are very sensitive. You can choose not to answer any of these questions. Remember these questions are private and we will not tell your parents how you answer. 74. Have you ever had sexual intercourse? Yes No 75. How old were you when you had sexual intercourse for the first time? I have never had sexual intercourse 11 years old or younger 12 years old 13 years old 14 years old 15 years old 16 years old 17 or more years old 76. During you life, with how many people have you had sexual intercourse? I have never had sexual intercourse 1 person 2 people 3 people 4 people 5 people 6 or more people	68. During your life how many times have you used heroin (also called smack, junk, or China White)? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 69. During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice)? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 70. During your life, how many times have you used ecstasy (also called MDMA)? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 71. During your life, how many times have you taken steroid pills or shots without a doctor’s prescription? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 77. During the last 3 months, with how many people did you have sexual intercourse? I have never had sexual intercourse I have had sexual intercourse, but not during the last 3 months 1 person 2 people 3 people 4 people 5 people 6 or more people 78. Did you drink alcohol or use drugs before you had sexual intercourse the last time? I have never had sexual intercourse Yes No 79. The last time you had sexual intercourse, did you or your partner use a condom? I have never had sexual intercourse Yes No 80. The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy (Select only one)? I have never had sexual intercourse No method was used to prevent pregnancy Birth control pills Condoms Depo-Provera (injectable birth control) Withdrawal Some other method Not sure 81. How many times have you been pregnant or gotten someone pregnant? I have never had sexual intercourse 0 times 1 time 2 or more times
IV. Physical Activity 82. During the past 7 days, on how many days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 83. During the past 7 days, on how many days did you exercise or participate in physical activity for at least 20 minutes that did not make you sweat and breathe hard, such as fast walking, slow bicycling, skating, pushing a lawn mower, or mopping floors? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days			84. During the past 7 days, on how many days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 85. Do your parent(s) limit the amount of time that you spend watching television? Yes No 86. On an average school day, how many hours do you usually spend reading for fun (books/magazines/newspapers)? I do not read for fun on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 87. On an average school day, how many hours do you watch TV (or DVD/videos)? I do not watch TV on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day
88. On an average school day, how many hours do you listen to music (radio/tapes/CDs/MP3s)? I do not listen to music on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 89. On an average school day, how many hours do you play with video or handheld games? I do not play with video games on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 90. On an average school day, how many hours do you use a computer for something that is not school work? I do not use a computer for something that is not school work on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day			91. On an average school day, how many hours do you talk on the phone? I do not talk on the phone on an average school day Less than 30 minutes per day Between 30 minutes and 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 or more hours per day 92. On an average school day, how many hours do you use a cell phone or PDA for things other than talking on the phone, like texting or surfing the web? I do not use my cell phone for things other than talking on an average school day Less than 30 minutes per day Between 30 minutes and 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 or more hours per day 93. On an average school day, how many hours do you spend using social network sites like AIM, yahoo messenger, facebook, twitter, myspace, second life, other? I do not use social network sites on an average school day Less than 30 minutes per day Between 30 minutes and 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 or more hours per day 94. On an average school day, how many hours do you spend reading, writing, or responding to blogs? I do not blog on an average school day Less than 30 minutes per day Between 30 minutes and 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 or more hours per day

95. On an average school day, how many hours do you use more than one type of media at the same time (like music & computer, or TV & reading)? I do not use more than one type of media on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 96. Do your parent(s) use internet filters or other methods of parental supervision when you are on the Internet or watching television? Yes No 97. Do you have access to R-rated movies and videos or mature rated video games? Yes No 98. Are there family rules about what television programs you are allowed to watch? Yes No 99. In an average week when you are in school, on how many days do you go to physical education (PE) classes? 0 days 1 day 2 days 3 days 4 days 5 days

100. How often do you participate in organized or team sports? (Include any teams run by your school or community) I do not participate in organized sports Daily Twice a week Weekly Every other week Once a month Less than once a month 101. Compared to other children your age, do you consider yourself: Much more active than other children Somewhat more active than other children About as active as other children Less active than other children Much less active than other children V. Eating 102. During the past 7 days, how many times did your family eat a meal together? Never Once Twice 3 times 4 times 5 times 6 times 7 or more times VI. Sleep Behavior 103. On a typical night, do you have trouble sleeping? Yes No

104. Do you snore? Yes No 105. Are you a restless sleeper? Yes No 106. Do you wake up during the night? Yes No 107. How many hours of sleep do you get on a typical night? More than 8 hours 6-8 hours 4-5 hours Less than 4 hours 108. Are you sleepy during the day? Yes No VII. School Performance 109. Has someone from school or a doctor ever told you that you have a learning disability? Yes No 110. Do you consider yourself an: A student B student C student D student F student 111. Do you worry about how you are doing right now or in the future? Yes No

VIII. Communication 112. How much have your parent(s) spoken with you about not smoking? Not at all Somewhat A moderate amount A great deal 113. How much have your parent(s) spoken with you about not drinking? Not at all Somewhat A moderate amount A great deal 114. How much have your parent(s) spoken with you about not using drugs? Not at all Somewhat A moderate amount A great deal 115. How much have your parent(s) spoken with you about birth control? Not at all Somewhat A moderate amount A great deal 116. How much have your parent(s) spoken with you about sexually transmitted diseases? Not at all Somewhat A moderate amount A great deal