2013 and 2015 Youth Risk Behavior Survey
2013 - 2015 Youth Risk Behavior Surveys
Appx E - Youth Risk Behavior Survey Questionnaire
2013 and 2015 Youth Risk Behavior Survey
OMB: 0920-0493
Appendix E. Youth Risk Behavior Survey Questionnaire
Form Approved
OMB No.: 0920-0493
Expiration Date:
2013 National
Youth Risk Behavior Survey
This survey is about health behavior. It has been developed so you can tell us what you do that may affect your health. The information you give will be used to improve health education for young people like yourself.
DO NOT write your name on this survey. The answers you give will be kept private. No one will know what you write. Answer the questions based on what you really do.
Completing the survey is voluntary. Whether or not you answer the questions will not affect your grade in this class. If you are not comfortable answering a question, just leave it blank.
The questions that ask about your background will be used only to describe the types of students completing this survey. The information will not be used to find out your name. No names will ever be reported.
Make sure to read every question. Fill in the ovals completely. When you are finished, follow the instructions of the person giving you the survey.
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including 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 Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-0493)
Thank you very much for your help.
DIRECTIONS
Use a #2 pencil only.
Make
dark marks.Fill in a response like this: A B C D
If you change your answer, erase your old answer completely.
1. How old are you?
A. 12 years old or younger
B. 13 years old
C. 14 years old
D. 15 years old
E. 16 years old
F. 17 years old
G. 18 years old or older
2. What is your sex?
A. Female
B. Male
3. In what grade are you?
A. 9th grade
B. 10th grade
C. 11th grade
D. 12th grade
E. Ungraded or other grade
4. Are you Hispanic or Latino?
A. Yes
B. No
5. What is your race? (Select one or more responses.)
A. American Indian or Alaska Native
B. Asian
C. Black or African American
D. Native Hawaiian or Other Pacific Islander
E. White
6. How tall are you without your shoes on?
Directions: Write your height in the shaded blank boxes. Fill in the matching oval below each number.
Example
-
Height
Height
Feet
Inches
Feet
Inches
5
7
3
0
3
0
4
1
4
1
5
2
5
2
6
3
6
3
7
4
7
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
7. How much do you weigh without your shoes on?
Directions: Write your weight in the shaded blank boxes. Fill in the matching oval below each number.
Example
-
Weight
Weight
Pounds
Pounds
1
5
2
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
5
5
5
5
6
6
6
6
7
7
7
7
8
8
8
8
9
9
9
9
The next 5 questions ask about safety.
8. When you rode a bicycle during the past 12 months, how often did you wear a helmet?
A. I did not ride a bicycle during the past 12 months
B. Never wore a helmet
C. Rarely wore a helmet
D. Sometimes wore a helmet
E. Most of the time wore a helmet
F. Always wore a helmet
9. How often do you wear a seat belt when riding in a car driven by someone else?
A. Never
B. Rarely
C. Sometimes
D. Most of the time
E. Always
10. 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?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
11. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?
A. I did not drive a car or other vehicle during the past 30 days
B. 0 times
C. 1 time
D. 2 or 3 times
E. 4 or 5 times
F. 6 or more times
12. During the past 30 days, on how many days did you text or e-mail while driving a car or other vehicle?
A. I did not drive a car or other vehicle during the past 30 days
B. 0 days
C. 1 or 2 days
D. 3 to 5 days
E. 6 to 9 days
F. 10 to 19 days
G. 20 to 29 days
H. All 30 days
The next 11 questions ask about violence-related behaviors.
13. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club?
A. 0 days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
14. During the past 30 days, on how many days did you carry a gun?
A. 0 days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
15. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club on school property?
A. 0 days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
16. During the past 30 days, on how many days did you not go to school because you felt you would be unsafe at school or on your way to or from school?
A. 0 days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
17. During the past 12 months, how many times has someone threatened or injured you with a weapon such as a gun, knife, or club on school property?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or 7 times
F. 8 or 9 times
G. 10 or 11 times
H. 12 or more times
18. During the past 12 months, how many times were you in a physical fight?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or 7 times
F. 8 or 9 times
G. 10 or 11 times
H. 12 or more times
19. During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
20. During the past 12 months, how many times were you in a physical fight on school property?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or 7 times
F. 8 or 9 times
G. 10 or 11 times
H. 12 or more times
21. Have you ever been physically forced to have sexual intercourse when you did not want to?
A. Yes
B. No
22. During the past 12 months, how many times did someone you were dating or going out with physically hurt you on purpose? (Count such things as being hit, slammed into something, or injured with an object or weapon.)
A. I did not date or go out with anyone during the past 12 months
B. 0 times
C. 1 time
D. 2 to 3 times
E. 4 to 5 times
F. 6 or more times
23. During the past 12 months, how many times did someone you were dating or going out with force you to do sexual things that you did not want to do? (Count such things as kissing, touching, or being physically forced to have sexual intercourse.)
A. I did not date or go out with anyone during the past 12 months
B. 0 times
C. 1 time
D. 2 to 3 times
E. 4 to 5 times
F. 6 or more times
The next 2 questions ask about bullying. Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when 2 students of about the same strength or power argue or fight or tease each other in a friendly way.
24. During the past 12 months, have you ever been bullied on school property?
A. Yes
B. No
25. During the past 12 months, have you ever been electronically bullied? (Count being bullied through e-mail, chat rooms, instant messaging, websites, or texting.)
A. Yes
B. No
The next 5 questions ask about sad feelings and attempted suicide. Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life.
26. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?
A. Yes
B. No
27. During the past 12 months, did you ever seriously consider attempting suicide?
A. Yes
B. No
28. During the past 12 months, did you make a plan about how you would attempt suicide?
A. Yes
B. No
29. During the past 12 months, how many times did you actually attempt suicide?
A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
30. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?
A. I did not attempt suicide during the past 12 months
B. Yes
C. No
The next 10 questions ask about tobacco use.
31. Have you ever tried cigarette smoking, even one or two puffs?
A. Yes
B. No
32. How old were you when you smoked a whole cigarette for the first time?
A. I have never smoked a whole cigarette
B. 8 years old or younger
C. 9 or 10 years old
D. 11 or 12 years old
E. 13 or 14 years old
F. 15 or 16 years old
G. 17 years old or older
33. During the past 30 days, on how many days did you smoke cigarettes?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
34. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
A. I did not smoke cigarettes during the past 30 days
B. Less than 1 cigarette per day
C. 1 cigarette per day
D. 2 to 5 cigarettes per day
E. 6 to 10 cigarettes per day
F. 11 to 20 cigarettes per day
G. More than 20 cigarettes per day
35. During the past 30 days, how did you usually get your own cigarettes? (Select only one response.)
A. I did not smoke cigarettes during the past 30 days
B. I bought them in a store such as a convenience store, supermarket, discount store, or gas station
C. I bought them from a vending machine
D. I gave someone else money to buy them for me
E. I borrowed (or bummed) them from someone else
F. A person 18 years old or older gave them to me
G. I took them from a store or family member
H. I got them some other way
36. During the past 30 days, on how many days did you smoke cigarettes on school property?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
37. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?
A. Yes
B. No
38. During the past 12 months, did you ever try to quit smoking cigarettes?
A. I did not smoke during the past 12 months
B. Yes
C. No
39. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
40. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
The next 6 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.
41. During your life, on how many days have you had at least one drink of alcohol?
A. 0 days
B. 1 or 2 days
C. 3 to 9 days
D. 10 to 19 days
E. 20 to 39 days
F. 40 to 99 days
G. 100 or more days
42. How old were you when you had your first drink of alcohol other than a few sips?
A. I have never had a drink of alcohol other than a few sips
B. 8 years old or younger
C. 9 or 10 years old
D. 11 or 12 years old
E. 13 or 14 years old
F. 15 or 16 years old
G. 17 years old or older
43. During the past 30 days, on how many days did you have at least one drink of alcohol?
A. 0 days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F. 20 to 29 days
G. All 30 days
44. 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?
A. 0 days
B. 1 day
C. 2 days
D. 3 to 5 days
E. 6 to 9 days
F. 10 to 19 days
G. 20 or more days
45. During the past 30 days, what is the largest number of alcoholic drinks you had in a row, that is, within a couple of hours?
A. I did not drink alcohol during the past 30 days
B. 1 or 2 drinks
C. 3 drinks
D. 4 drinks
E. 5 drinks
F. 6 or 7 drinks
G. 8 or 9 drinks
H. 10 or more drinks
46. During the past 30 days, how did you usually get the alcohol you drank?
A. I did not drink alcohol during the past 30 days
B. I bought it in a store such as a liquor store, convenience store, supermarket, discount store, or gas station
C. I bought it at a restaurant, bar, or club
D. I bought it at a public event such as a concert or sporting event
E. I gave someone else money to buy it for me
F. Someone gave it to me
G. I took it from a store or family member
H. I got it some other way
The next 3 questions ask about marijuana use. Marijuana also is called grass or pot.
47. During your life, how many times have you used marijuana?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 to 99 times
G. 100 or more times
48. How old were you when you tried marijuana for the first time?
A. I have never tried marijuana
B. 8 years old or younger
C. 9 or 10 years old
D. 11 or 12 years old
E. 13 or 14 years old
F. 15 or 16 years old
G. 17 years old or older
49. During the past 30 days, how many times did you use marijuana?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
The next 10 questions ask about other drugs.
50. During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
51. 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?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
52. During your life, how many times have you used heroin (also called smack, junk, or China White)?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
53. During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice)?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
54. During your life, how many times have you used ecstasy (also called MDMA)?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
55. During your life, how many times have you used hallucinogenic drugs, such as LSD, acid, PCP, angel dust, mescaline, or mushrooms?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
56. During your life, how many times have you taken steroid pills or shots without a doctor's prescription?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
57. During your life, how many times have you taken a prescription drug (such as OxyContin, Percocet, Vicodin, codeine, Adderall, Ritalin, or Xanax) without a doctor's prescription?
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
F. 40 or more times
58. During your life, how many times have you used a needle to inject any illegal drug into your body?
A. 0 times
B. 1 time
C. 2 or more times
59. During the past 12 months, has anyone offered, sold, or given you an illegal drug on school property?
A. Yes
B. No
The next 7 questions ask about sexual behavior.
60. Have you ever had sexual intercourse?
A. Yes
B. No
61. How old were you when you had sexual intercourse for the first time?
A. I have never had sexual intercourse
B. 11 years old or younger
C. 12 years old
D. 13 years old
E. 14 years old
F. 15 years old
G. 16 years old
H. 17 years old or older
62. During your life, with how many people have you had sexual intercourse?
A. I have never had sexual intercourse
B. 1 person
C. 2 people
D. 3 people
E. 4 people
F. 5 people
G. 6 or more people
63. During the past 3 months, with how many people did you have sexual intercourse?
A. I have never had sexual intercourse
B. I have had sexual intercourse, but not during the past 3 months
C. 1 person
D. 2 people
E. 3 people
F. 4 people
G. 5 people
H. 6 or more people
64. Did you drink alcohol or use drugs before you had sexual intercourse the last time?
A. I have never had sexual intercourse
B. Yes
C. No
65. The last time you had sexual intercourse, did you or your partner use a condom?
A. I have never had sexual intercourse
B. Yes
C. No
66. The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy? (Select only one response.)
A. I have never had sexual intercourse
B. No method was used to prevent pregnancy
C. Birth control pills
D. Condoms
E. An IUD (such as Mirena or ParaGard ) or implant (such as Implanon or Nexplanon)
F. A shot (such as Depo-Provera), patch (such as OrthoEvra), or birth control ring (such as NuvaRing)
G. Withdrawal or some other method
H. Not sure
The next 5 questions ask about body weight.
67. How do you describe your weight?
A. Very underweight
B. Slightly underweight
C. About the right weight
D. Slightly overweight
E. Very overweight
68. Which of the following are you trying to do about your weight?
A. Lose weight
B. Gain weight
C. Stay the same weight
D. I am not trying to do anything about my weight
69. During the past 30 days, did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?
A. Yes
B. No
70. During the past 30 days, did you take any diet pills, powders, or liquids without a doctor's advice to lose weight or to keep from gaining weight? (Do not count meal replacement products such as Slim Fast.)
A. Yes
B. No
71. During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?
A. Yes
B. No
The next 9 questions ask 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.
72. During the past 7 days, how many times did you 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.)
A. I did not drink 100% fruit juice during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
73. During the past 7 days, how many times did you eat fruit? (Do not count fruit juice.)
A. I did not eat fruit during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
74. During the past 7 days, how many times did you eat green salad?
A. I did not eat green salad during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
75. During the past 7 days, how many times did you eat potatoes? (Do not count french fries, fried potatoes, or potato chips.)
A. I did not eat potatoes during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
76. During the past 7 days, how many times did you eat carrots?
A. I did not eat carrots during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
77. During the past 7 days, how many times did you eat other vegetables? (Do not count green salad, potatoes, or carrots.)
A. I did not eat other vegetables during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
78. During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not count diet soda or diet pop.)
A. I did not drink soda or pop during the past 7 days
B. 1 to 3 times during the past 7 days
C. 4 to 6 times during the past 7 days
D. 1 time per day
E. 2 times per day
F. 3 times per day
G. 4 or more times per day
79. During the past 7 days, how many glasses of milk did you drink? (Count 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.)
A. I did not drink milk during the past 7 days
B. 1 to 3 glasses during the past 7 days
C. 4 to 6 glasses during the past 7 days
D. 1 glass per day
E. 2 glasses per day
F. 3 glasses per day
G. 4 or more glasses per day
80. During the past 7 days, on how many days did you eat breakfast?
A. 0 days
B. 1 day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
G. 6 days
H. 7 days
The next 6 questions ask about physical activity.
81. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)
A. 0 days
B. 1 day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
G. 6 days
H. 7 days
82. On how many of the past 7 days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting?
A. 0 days
B. 1 day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
G. 6 days
H. 7 days
83. On an average school day, how many hours do you watch TV?
A. I do not watch TV on an average school day
B. Less than 1 hour per day
C. 1 hour per day
D. 2 hours per day
E. 3 hours per day
F. 4 hours per day
G. 5 or more hours per day
84. On an average school day, how many hours do you play video or computer games or use a computer for something that is not school work? (Count time spent on things such as Xbox, PlayStation, an iPod, an iPad or other tablet, a smartphone, YouTube, Facebook or other social networking tools, and the Internet.)
A. I do not play video or computer games or use a computer for something that is not school work
B. Less than 1 hour per day
C. 1 hour per day
D. 2 hours per day
E. 3 hours per day
F. 4 hours per day
G. 5 or more hours per day
85. In an average week when you are in school, on how many days do you go to physical education (PE) classes?
A. 0 days
B. 1 day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
86. During the past 12 months, on how many sports teams did you play? (Count any teams run by your school or community groups.)
A. 0 teams
B. 1 team
C. 2 teams
D. 3 or more teams
The next 6 questions ask about other health-related topics.
87. Have you ever been taught about AIDS or HIV infection in school?
A. Yes
B. No
C. Not sure
88. Have you ever been tested for HIV, the virus that causes AIDS? (Do not count tests done if you donated blood.)
A. Yes
B. No
C. Not sure
89. When you are outside for more than one hour on a sunny day, how often do you wear sunscreen with an SPF of 15 or higher?
A. Never
B. Rarely
C. Sometimes
D. Most of the time
E. Always
90. During the past 12 months, how many times did you use an indoor tanning device such as a sunlamp, sunbed, or tanning booth? (Do not count getting a spray-on tan.)
A. 0 times
B. 1 or 2 times
C. 3 to 9 times
D. 10 to 19 times
E. 20 to 39 times
91. Has a doctor or nurse ever told you that you have asthma?
A. Yes
B. No
C. Not sure
92. On an average school night, how many hours of sleep do you get?
A. 4 or less hours
B. 5 hours
C. 6 hours
D. 7 hours
E. 8 hours
F. 9 hours
G. 10 or more hours
This is the end of the survey.
Thank you very much for your help.
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