GPRA Student Survey

OMB No. 0930-0297

Expiration Date: xx/xx/xx

Attachment 9:

Data Collection Instrument – GPRA Student Survey

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. The OMB control number for this project is 0930-0297. Public reporting burden for this collection of information is estimated to average 7 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, One Choke Cherry Road, Room 8-1099, Rockville, Maryland 20857.

GPRA Student Survey

What is your sex?

1. Male

2. Female

What grade are you in?

1. 4^th grade

2. 5^th grade

3. 6^th grade

4. 7^th grade

5. 8^th grade

6. 9^th grade

7. 10^th grade

8. 11^th grade

9. 12^th grade

10. Other grade (please specify): _______

Are you of Hispanic or Latino origin?

1. No

2. Yes

What is your race? Mark all that apply.

(a) American Indian or Alaska Native

(b) Asian

(c) Black or African American

(d) Native Hawaiian or Other Pacific Islander

(e) White

During the past 30 days, how many days did you not go to school because you felt you would be unsafe at school or on your way to and from school?

(a) None

(b) 1 day

(c) 2 or 3 days

(c) 4 or 5 days

(d) 6 or more days

During the past 12 months, how many times on school property have you been in a physical fight?

(a) 0 times

(b) 1 time

(c) 2 or 3 times

(d) 4 or more times

During the past 30 days, on how many days did you use marijuana?

(a) 0 days

(b) 1-2 days

(c) 3-9 days

(d) 10-19 days

During the past 30 days, on how many days did you use at least one drink of alcohol?

(a) 0 days

(b) 1-2 days

(c) 3-9 days

(d) 10-19 days

(e) 20-30 days

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