People In My Life

					OMB Number: Exp Date:
PEOPLE IN MY LIFE		I D #:
	Almost Never or Never True		Sometimes True	Often True		Almost Always or Always True
a. I like to eat ice cream	O		O	O		O
b. I like to wash dishes	O		O	O		O
1. My parents respect my feelings	O		O	O		O
2. My parents listen to what I have to say	O		O	O		O
3. My parents accept me as I am	O		O	O		O
4. My parents understand me	O		O	O		O
5. My parents care about me	O		O	O		O
6. I trust my parents	O		O	O		O
7. I can count on my parents to help me when I have a problem	O		O	O		O
8. My parents can tell when I am upset about something.	O		O	O		O
9. I talk to my parents when I am having a problem	O		O	O		O
10. If my parents know that something is bothering me, they ask me about it	O		O	O		O
11. I share my thoughts and feelings with my parents with my parents	O		O	O		O
1 Public reporting burden of this collection of information is estimated to average 15 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 (???). 2. When I am away from home, my parents know where I am and who I am with	O		O	O		O
	Almost Never or Never True		Sometimes True	Often True		Almost Always or Always True
13. My home is a nice place to live	O		O	O		O
14. My parents pay attention to me	O		O	O		O
15. My parents don't understand what I am going through these days	O		O	O		O
16. I get upset easily with my parents	O		O	O		O
17. I feel angry with my parents	O		O	O		O
18. It's hard for me to talk to my parents	O		O	O		O
19. I feel scared in my home	O		O	O		O
20. I get along well with my parents	O		O	O		O
21. My parents are proud of the things I do	O		O	O		O
22. My friends respect my feelings	O		O	O		O
23. My friends listen to what I have to say	O		O	O		O
24. My friends accept me as I am	O		O	O		O
25. My friends understand me
26. My friends care about me
27. I trust my friends	O		O	O		O
28. I can count on my friends to help me when I have a problem	O		O	O		O
	Almost Never or Never True		Sometimes True	Often True		Almost Always or Always True
29. My friends can tell when I am upset about something	O		O	O		O
30. I talk to my friends when I am having a problem	O		O	O		O
31. If my friends know that something is bothering me, they ask me about it	O		O	O		O
32. I share my thoughts and feelings with my friends	O		O	O		O
33. I like to be with my friends	O		O	O		O
34. My friends pay attention to me	O		O	O		O
35. My friends don't understand what I am going through these days	O		O	O		O
36. I get upset easily with my friends	O		O	O		O
37. I feel angry with my friends.	O		O	O		O
38. I feel scared with my friends	O		O	O		O
39. It's hard for me to talk to my friends	O		O	O		O
40. I get along well with my friends	O		O	O		O
41. My friends are proud of the things I do	O		O	O		O
42. I think my friends are a bad influence on me	O		O	O		O
43. I wish I had more friends	O		O	O		O
44. If one of my friends asked me to skip school, I would do it	O		O	O		O
	Almost Never or Never True		Sometimes True	Often True		Almost Always or Always True
45. If I were at a party and one of my friends offered me some beer, I would drink it	O		O	O		O
46. If a friend asked to copy my test, I would let him or her do it	O		O	O		O
47. Doing well at school is important to my friends	O		O	O		O
48. My parents like and approve of my friends	O		O	O		O
49. Most mornings I look forward to going to school	O		O	O		O
50. I feel safe at my school	O		O	O		O
51. My school is a nice place to be	O		O	O		O
52. I like my teacher(s) this year	O		O	O		O
53. I like my class(es) this year	O		O	O		O
54. My teachers respect my feelings	O		O	O		O
55. My teachers understand me	O		O	O		O
56. I trust my teachers	O		O	O		O
57. My teachers pay a lot of attention to me	O		O	O		O
58. I get upset easily with my teachers	O		O	O		O
59. I feel angry with my teachers	O		O	O		O
60. I get along well with my teachers	O		O	O		O
	Almost Never or Never True		Sometimes True	Often True		Almost Always or Always True
61. It's hard for me to talk to my teachers	O		O	O		O
62. My teachers are proud of the things I do	O		O	O		O
63. I like to take part in class discussions and activities	O		O	O		O
64. I feel sure about how to do my work at school	O		O	O		O
65. I read better than most other kids my age	O		O	O		O
66. Doing well at school is important to me	O		O	O		O
67. There is a teacher at my school that I can count on when I have a problem	O		O	O		O
68. Kids in my school have a good chance to grow up and be successful	O		O	O		O
69. I feel scared at my school	O		O	O		O
70. There are a lot of drugs and gangs in my school	O		O	O		O
71. My school is a dangerous place to be	O		O	O		O
72. My neighborhood is a nice place to live	O		O	O		O
73. A lot of people in my neighborhood are friendly and helpful	O		O	O		O
74. Kids from my neighborhood have a good chance to grow up and be successful	O		O	O		O
75. I feel scared in my neighborhood	O		O	O		O

			Almost Never or Never True	Sometimes True		Often True		Almost Always or Always True
76. Lots of kids in my neighborhood get into trouble			O	O		O		O
77. There are a lot of drugs and gangs in my neighborhood			O	O		O		O
78. My neighborhood is a dangerous place to live			O	O		O		O
79. If you could go as far as you wanted in school, how far would you want to go?	Drop out of school now	Drop out of school before finishing high school			Finish high school		Finish college
	O	O			O		O
80. How far do you think you really will go?	I will drop out of school soon	I will drop out of school before I finish high school			I will finish high school		I will finish college
	O	O			O		O

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by