Attachment 1A Participant Hard Copy Survey 2012

OMB No: 0925-0610

W4 Expiration Date: 01/31/2013

2013

Generation Health Study Survey

September, 2012

Public reporting burden for this collection of information is estimated to average 35 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0610). Do not return the completed form to this address.

This survey asks about your health. You have agreed to participate in this ongoing study of health in U.S. adolescents and young adults. The information you give will be used to improve the health of students like you. Just like last year, this survey is confidential; what you say on this survey will not be revealed to anyone else. DO NOT write your name anywhere on this survey booklet. You will be identified by a special ID number. Your answers will be read by computer. Answer the questions based on what you really do, think, and feel. Make sure you read every question. You do not have to answer any question that makes you feel uncomfortable. When you are finished, place the completed survey in the envelope provided, seal it, and either return it to a NEXT Health Researcher OR mail it to the NEXT home office in the postage paid, addressed envelope provided.
INSTRUCTIONS FOR COMPLETING THE SURVEY Read all the printed answers before marking your choice. Mark the circle for the one answer that best fits your situation. Use a No. 2 pencil. Make heavy marks that fill the circle for your answer. Erase cleanly any answer you wish to change. Please do not make stray marks of any kind. Unless the question clearly says that you can fill in more than one circle, you should mark only one circle for your answer in the column below the question. Sometimes you will be asked to mark one circle in each column, as shown here:
EXAMPLE: About how many hours a day do you usually play games on a computer?
		Weekdays				Weekend
		 None at all				 None at all
		 About half an hour				 About half an hour
Sometimes you will be asked to select one choice for each statement. For these questions, make sure to “Mark one circle on each line” as shown here: EXAMPLE: How often do you do each of the following: (Mark one circle on each line)
	Often			Sometimes				Never
Swim								
Bowl								

1.	Are you currently attending high school, vocational school, or college? If YES, please indicate which type of school and the name of the school.
	 No, I have not attended school in the last 6 months
	 High School (write in below) ______________________________________
	 Technical/Vocational School (write in below) ______________________________________
	 Community College (write in below) ______________________________________
	 College/University (write in below) _______________________________________
2.	What is the most schooling you think you will complete?
	I will…
	 Not finish high school
	 Graduate from high school
	 Go to trade, technical or vocational school
	 Complete 2 years or less of college
	 Graduate from a 4-year college or university
	 Go to graduate or professional school

3.	On average, during the school year, how many hours per week do you work in paid or unpaid jobs?
	 None (zero)
	 5 hours or less per week
	 6 to 10 hours per week
	 11 to 15 hours per week
	 16 to 20 hours per week
	 21 to 25 hours per week
	 26 to 30 hours per week
	 More than 30 hours per week

4.	How much spending money do you have during an average month?
	 Less than $100 per month
	 $100 to $199 per month
	 $200 to $299 per month
	 $300 to $399 per month
	 $400 to $499 per month
	 $500 or more per month

5.	About how many hours a day do you usually play games on a computer or game console (Playstation, Xbox, GameCube, etc.) in your free time? (Please mark one circle for weekdays and one circle for weekend)
	Weekdays________________					Weekend____________________
		 None at all					 None at all
		 About half an hour a day					 About half an hour a day
		 About 1 hour a day					 About 1 hour a day
		 About 2 hours a day					 About 2 hours a day
		 About 3 hours a day					 About 3 hours a day
		 About 4 hours a day					 About 4 hours a day
		 About 5 hours a day					 About 5 hours a day
		 About 6 hours a day					 About 6 hours a day
		 About 7 or more hours a day					 About 7 or more hours a day

6.	Which of the following do you have in the room where you usually sleep?
	Computer	 No	 Yes
	Television	 No	 Yes
	Game Console	 No	 Yes

7.

About how many hours a day do you usually use a computer or cell phone for chatting on-line, internet, emailing, texting, tweeting or similar social networking (other than for a job or school work) during your free time? (Please mark one circle for weekdays and one circle for weekend)

Weekdays________________

Weekend______________________

 None at all

 None at all

 About half an hour a day

 About half an hour a day

 About 1 hour a day

 About 1 hour a day

 About 2 hours a day

 About 2 hours a day

 About 3 hours a day

 About 3 hours a day

 About 4 hours a day

 About 4 hours a day

 About 5 hours a day

 About 5 hours a day

 About 6 hours a day

 About 6 hours a day

 About 7 or more hours a day

 About 7 or more hours a day

SOURCE: HBSC 1990, 1994, 1998, 2002 (revised: weekly activity changed to daily; weekday/weekend split introduced; definition in brackets added).

8.	About how many hours a day do you usually watch television (including videos or DVDs) or use a DVD player in your free time? (Please mark one circle for weekdays and one circle for weekend)
	Weekdays				Weekend
		 None at all				 None at all
		 About half an hour a day				 About half an hour a day
		 About 1 hour a day				 About 1 hour a day
		 About 2 hours a day				 About 2 hours a day
		 About 3 hours a day				 About 3 hours a day
		 About 4 hours a day				 About 4 hours a day
		 About 5 hours a day				 About 5 hours a day
		 About 6 hours a day				 About 6 hours a day
		 About 7 or more hours a day				 About 7 or more hours a day

SOURCE: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/98, 2001/02 (Revised: weekday/weekend split introduced; response categories expanded; ‘videos’ included).

Different people have different reasons for deciding how much time they spend doing things. We want to know how true each of these reasons is for you.

9.	The amount of free time I spend watching TV and videos, playing video games, and using computers is because: (Please mark one circle for each line on a scale from 1 to 7 where 1 means Not at all True and 7 means Very True.)
		Not at all True			Somewhat True			Very True
		1	2	3	4	5	6	7
	a. It fits in with the person I am							
	b. I enjoy it							
	c. It is something my friends approve of							
	d. I feel guilty if I do otherwise							
	e. It is personally important to me							
	f. I have the opportunity or it is part of how my day is structured							

All families are different (for example, not everyone lives with both their parents, sometimes people live with just one parent, or they have two homes or live with two families). We would like to know about the home where you live all or most of the time.

10a.		Please answer this question for the home where you live all or most of the time and mark all the people who live there.
		Adults
		 Mother
		 Father
		 Stepmother (or father’s girlfriend)
		 Stepfather (or mother’s boyfriend)
		 Spouse or romantic partner
		 Roommates or housemates
		 Grandmother
		 Grandfather
		 I live alone
		 I live in a foster home or children’s home
		 Other adults: please write down their relationship to you (aunt, uncle, family friend) ______________________________________________________

10b.	Do you have any children of your own (including step-children or adopted children)?
		No
		Yes, one child
		Yes, two children
		Yes, three or more children

11.	If you are female, are you currently pregnant or breastfeeding? (SKIP THIS QUESTION if you are male)
		No
		Yes, pregnant
		Yes, breastfeeding

12.	At this time, do you feel you are…
			Very underweight
			Somewhat underweight
			About the right weight
			Somewhat overweight
			Very overweight

Physical activity can be done in sports, school activities, playing with friends, or walking to work or school. Some examples of physical activity are running, brisk walking, rollerblading, biking, dancing, skateboarding, swimming, soccer, basketball, football, & surfing.

For this next question, add up all the time you spent in physical activity each day.

13.	Over the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day?
	0 days	1 day	2 days	3 days	4 days	5 days	6 days	7 days

       

SOURCE: Prochaska JJ, Sallis JF, Long B. (2001). A physical activity screening measure for use with adolescents in primary care. Archives of Pediatrics & Adolescent Medicine. 155: 554-559.

Adapted for use in HBSC survey 2001/02.

Vigorous physical activity is any activity that increases your heart rate and makes you get out of breath some of the time.

For this next question, add up all the time you spent in vigorous physical activity each day.

14.	How many HOURS a week do you usually engage in vigorous physical activity so much that you get out of breath or sweat?
		None
		About half an hour
		About 1 hour
		About 2 to 3 hours
		About 4 to 6 hours
		7 hours or more

SOURCE: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/98. 2001/02 (optional).

15.	Think about the last 7 days. How often did you do each of these when making plans for vigorous physical activity? (Please mark one circle for each line)
		Not at all	Seldom	Sometimes	Often	Very Often
	a. I planned when to exercise					
	b. I planned how often to exercise					
	c. I planned where to exercise					

Adapted from Dombrowski & Luszczynska Applied Psychology 2009;58:257-273.

16a.	During the past 12 months, how many individual sports did you participate in on a competitive level, such as varsity or junior varsity sports, intramurals, sport clubs or leagues, or out-of-school programs?
		 None
		 One
		 Two
		 Three
		 Four or more

16b. If one or more, what competitive sports did you participate in?

1._________________________________________________

2._________________________________________________

3. _________________________________________________

4. _________________________________________________

5. _________________________________________________

6. _________________________________________________

Medicine & Science in Sports & Exercise. A Collection of Physical Activity Questionnaires for Health-Related Research. 29 (6) Supplement: 79-82, June 1997.

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17.	How long does it usually take you to travel to school from your home? If no longer attending school, how long does it take you to travel from your home to work? (Please mark one circle only)
		I do not currently work or attend school
		Less than 5 minutes
		5-15 minutes
		15-30 minutes
		30 minutes to 1 hour
		More than 1 hour

18. In a typical week, how many days do you use the following to get to and from school or work? (Please mark one circle for each line)
	Never	1 day	2 days	3 days	4 days	5 days	6 days	7 days
a. Walk								
b. Ride a bike								
c. Drive								
d. Ride in a vehicle with someone else								
e. Public transportation (for example, bus, train, or school bus)								
f. Other: _________________								

Different people have different reasons for deciding whether or not to do things. We want to know how true each of these reasons is for you.

19.	The amount of time I am physically active during a typical day is because: (Please mark one circle for each line on a scale from 1 to 7 where 1 means Not at all True and 7 means Very True.)
		Not at all True			Somewhat True			Very True
		1	2	3	4	5	6	7
	a. It fits with how I see myself							
	b. I enjoy it							
	c. My parents, other family members, or friends tell me to do it							
	d. I feel guilty if I do otherwise							
	e. It is personally important to me							
	f. I am required to do it							

Adapted from Ryan, R. M., & Connell, J. P. (1989). Perceived locus of causality and internalization: Examining reasons for acting in two domains. Journal of Personality and Social Psychology, 57, 749-761.

The next four questions ask you to fill in times that you wake up and go to sleep. For example, if you usually wake up at 10 minutes after 6 in the morning you would enter:
0 6 : 1 0	 AM  PM

20. On days that you go to school, work, or similar activities, what time do you usually wake up?

__ __ : __ __

 AM  PM

On those days, what time do you usually go to sleep the night or day before?

__ __ : __ __

 AM  PM

21. On days that you don’t have to get up at a certain time, what time do you usually wake up?

__ __ : __ __

 AM  PM

On those days, what time do you usually go to sleep the night or day before?

__ __ : __ __

 AM  PM

22. Over the past four weeks:

How often did you have trouble falling asleep?

(Please mark one circle only)

 Never in the past 4 weeks

 Less than once a week

 1 or 2 times a week

 3 or 4 times a week

 5 or more times a week

How often did you have trouble staying asleep through the night? For example, you woke up several times at night or woke up earlier than you planned to? (Please mark one circle only)

 Never in the past 4 weeks

 Less than once a week

 1 or 2 times a week

 3 or 4 times a week

 5 or more times a week

23. Based on what you have noticed or what others have told you, are there times when you snore or you stop breathing during your sleep?

 Yes

 No

[AddHealth]

24.	How often do you usually have breakfast within about two hours of waking (more than just coffee, milk or fruit juice)? (Please mark one circle for weekdays and one circle for weekend)
	Weekdays__________________						Weekend________________________
		 I never have breakfast during weekdays				 I never have breakfast during the weekend
		 One day				 One day (Saturday OR Sunday)
		 Two days				 Two days (Saturday AND Sunday)
		 Three days
		 Four days
		 Five days

Source: HBSC survey 2002.

This question asks 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, school, work, restaurants, or anywhere else.

25.	During the past 7 days, how many times did you…?
	(Please mark one circle for each line)
		Never	1 to 3 times	4 to 6 times	1 time per day	2 times per day	3 times per day	4 or more times per day
	a. 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.)							
	b. Eat fruit? (Do not count fruit juice.)							
	c. Eat green vegetables such as leafy salad, broccoli, green beans, and peas?							
	d. Eat orange vegetables such as carrots or sweet potatoes?							
	e. Eat cooked or canned beans like refried or baked beans, lentil soup, or pork and beans?							
	f. Eat whole grain foods such as whole grain bread, whole wheat pasta, whole wheat crackers, brown or wild rice, popcorn, or oatmeal?							
	g. Drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not include diet soda or diet pop.)							
	h. Eat sweet or salty snacks such as chips, fries, candy, cookies, or cake?							

SOURCE: YRBS

Different people have different reasons for deciding whether or not to do things. We want to know how true each of these reasons is for you.

26.	I eat the way I do most days because: (Please mark one circle for each line on a scale from 1 to 7 where 1 means Not at all True and 7 means Very True.)
		Not at all True			Somewhat True			Very True
		1	2	3	4	5	6	7
	a. It fits with how I see myself							
	b. It makes me feel good							
	c. It is influenced by whether other people would be mad at me							
	d. I feel guilty if I do otherwise							
	e. It is personally important to me							
	f. It is what is easily available to eat							

Adapted from Ryan, R. M., & Connell, J. P. (1989). Perceived locus of causality and internalization: Examining reasons for acting in two domains. Journal of Personality and Social Psychology, 57, 749-761.

27. (Please mark one circle for each line)
	Never		Less than once a week	1-2 days a week		3-4 days a week		5-6 days a week		Every day
a. How often do you have breakfast together with a parent, stepparent, or guardian?									
b. How often do you have an evening meal together with a parent, stepparent, or guardian?									
c. How often do you watch television during a meal at home?									
d. How often do you have a meal with friends outside of school/work?									

28.	Where do you usually eat your mid-day meal on school or work days?
	 At school/work  At home  At someone else’s home  In a snack-bar, fast food restaurant, café  Somewhere else: (Please write down where) ___________________________________  I never eat a mid-day meal

29.	How often do you eat in a fast food restaurant (for example, McDonalds, KFC, Pizza Hut, Taco Bell)?
		Never
		Rarely (less than once a month)
		Once a month
		2-3 times a month
		Once a week
		2-4 days a week
		5 or more days a week

30.	How much do you weigh without clothes? (In pounds) If you don’t know how much you weigh (within a few pounds), fill in this circle 

Example-–152 lbs.

Weight in pounds				Weight in 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	 4	 4
	 5	 5			 5	 5
	 6	 6			 6	 6
	 7	 7			 7	 7
	 8	 8			 8	 8
	 9	 9			 9	 9

SOURCE: YRBS. HBSC surveys 1997/98 (optional package), 20021/02 (mandatory).

31.	How tall are you without shoes? If you don’t know how tall you are (within an inch or two), fill in this circle 

Example-–5 ft., 2 in.

Feet	Inches		Feet	Inches
5	2
 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

SOURCE: HBSC surveys 1997/98 (optional package), 20021/02 (mandatory).

32. Have you heard about (or you aware of): (Please mark one circle for each line)
-My Pyramid?	 No	 Yes
-The Dietary Guidelines for Americans?	 No	 Yes
-MyPlate?	 No	 Yes

	33. At present, are you on a diet or doing something else to lose weight?
		No, my weight is fine (skip to question 35)
		No, but I should lose some weight (skip to question 35)
		No, because I need to put on weight (skip to question 35)
		Yes

SOURCE: HBSC surveys 1993/94, 1997/988, 2001/02 (revised: definition was expanded to include ‘doing something else’; response category 3 was added).

Different people have different reasons for deciding whether or not to do things. We want to know how true each of these reasons is for you.

34.	I am doing something to lose weight because: (Please mark one circle for each line on a scale from 1 to 7 where 1 means Not at all True and 7 means Very True.)
		Not at all True			Somewhat True			Very True
		1	2	3	4	5	6	7
	a. It fits with how I see myself							
	b. It makes me feel good							
	c. My family, doctor, or friends tell me to do it							
	d. I feel guilty if I do otherwise							
	e. It is personally important to me							
	f. It is part of how my day is structured							

35.	Would you say your health is…? (Please mark one circle)
		Excellent
		Good
		Fair
		Poor

SOURCE: Idler, E. L. & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21-37. HBSC 2002

36.	How often do you brush your teeth?
			More than once a day
			Once a day
			At least once a week but not daily
			Less than once a week
			Never

SOURCE: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/98, 2001/02. Status for 2005/06: Unchanged.

37.	In the last 6 months, how often have you had the following…? (Please mark one circle for each line)
		Rarely or never	About every month	About every week	More than once a week	About every day
	a. Headache					
	b. Stomach-ache					
	c. Back ache					
	d. Feeling low					
	e. Irritability or bad temper					
	f. Feeling nervous					
	g. Difficulties in getting to sleep					
	h. Feeling dizzy					

SOURCE: HBSC 1986, 1990, 1994, 1998, 2002, 2005, 2009

38.	During the last month have you taken any medicine or tablets for the following?
		No	Yes, once	Yes, more than once
	a. Headache			
	b. Stomach-ache			
	c. Difficulties in getting to sleep			
	d. Nervousness			
	e. Something else If yes, what? ___________________			

U.S. HBSC Survey 2001/2002, 2005, 2009

39.	Do you have a long-term illness, disability, or medical condition (like diabetes, arthritis, asthma, allergy, ADHD or cerebral palsy) that has been diagnosed by a doctor?
	 Yes. If yes, please write what they are: _________________________________  No (skip to Question 42)

40.	Do you take medicine for your long-term illness, disability or medical condition?
	 Yes  No If yes, please write what it is: _________________________________
41.	Does your long-term illness, disability or medical condition affect your attendance and performance at school or work?
	 Yes  No

Source: HBSC 2005/06 (adapted from Finnish and Canadian HBSC national surveys)

42.	Think about how you have been feeling over the last 7 days. How often has each of these been true? (Please mark one circle for each line)
		Never	Almost never	Sometimes	Often	Almost always
	I felt like I couldn’t do anything right.					
	I felt everything in my life went wrong.					
	I felt unhappy.					
	I felt lonely.					
	I felt sad.					
	I felt alone.					
	I thought that my life was bad.					
	I could not stop feeling sad.					

Irwin et al., 2010 Qual Life Res - pediatric PROMIS depressive symptoms scale

43.	How much does your mother (or female guardian) really know about…? (Please mark one circle for each line)
		Don’t have/see mother/ guardian	She doesn’t know anything	She knows a little	She knows a lot
	Who your friends are				
	How you spend your money				
	Where you are after school or work				
	Where you go at night				
	What you do with your free time				

44.	How much does your father (or male guardian) really know about…? (Please mark one circle for each line)
		Don’t have/see father/ guardian	He doesn’t know anything	He knows a little	He knows a lot
	Who your friends are				
	How you spend your money				
	Where you are after school or work				
	Where you go at night				
	What you do with your free time				

45.	In general, how satisfied are you with the relationships in your family? (Mark one circle next to the number that best describes your feelings)			10	We have very good relationships in our family
				9
				8
				7
				6
				5
				4
				3
				2
				1
				0	We have very bad relationships in our family

46.

How important is it to your parents/guardians that you … (Please mark one circle for each line on a scale from 1 to 7 where 1 means Not at all and 7 means Extremely.)

Not at all 1

2

3

Somewhat 4

5

6

Extremely 7

Get daily physical activity and/or exercise?















Eat a healthful diet (including fruits & vegetables, and limiting junk food, sweets & fatty foods)?















Limit your time watching TV and videos, playing video games, or using the computer?















Not use alcohol















Not smoke cigarettes















Not use marijuana















Not physically hurt or threaten to hurt a romantic partner















Not swear at, insult, call names, and/or treat disrespectfully a romantic partner















Adapted from the National Survey on Drug Use and Health

47.	Is your group of friends well accepted by your parents?
		Almost always
		Sometimes
		Never, almost never
		They haven’t met your group of friends

48.	Think of your closest male friends. List up to three of your closest male friends. List your best male friend first, then your next best friend, and so on. Include boys who are friends and boyfriends.
	Enter their initials, first name, or nick name:	Male Friend 1: _____	Male Friend 2: _____	Male Friend 3: _____
	If they are in school, what grade are they in? If they are NOT in school, how old are they?	Grade: Age: _____	Grade: Age: ____	Grade: Age: ____
	Fill in one circle under each friend:
	a. You went to his house in the last seven days when a parent was present.	  Yes No	  Yes No	  Yes No
	b. You went to his house in the last seven days without a parent present.	  Yes No	  Yes No	  Yes No
	c. He came to your house in the last seven days when a parent was present.	  Yes No	  Yes No	  Yes No
	d. He came to your house in the last seven days without a parent present.	  Yes No	  Yes No	  Yes No
	e. You met him after school or work to hang out or go somewhere in the last seven days.	  Yes No	  Yes No	  Yes No
	f. You spent time with him last weekend.	  Yes No	  Yes No	  Yes No
	g. You talked with him about a problem in the last seven days.	  Yes No	  Yes No	  Yes No
	h. You talked with him on the telephone in the last seven days.	  Yes No	  Yes No	  Yes No
	i. You emailed, text messaged, or twittered him in the last seven days.	  Yes No	  Yes No	  Yes No
	j. You and he are linked through your online network profile (‘friend’ on Facebook, ‘follower’ on Twitter).	  Yes No	  Yes No	  Yes No
	k. You exercised or played sports with him in the last seven days.	  Yes No	  Yes No	  Yes No
	l. You ate a meal with him in the last seven days.	  Yes No	  Yes No	  Yes No
	m. You played computer games with him in the last seven days.	  Yes No	  Yes No	  Yes No
	n. You watched television or videos/DVDs with him in the last seven days.	  Yes No	  Yes No	  Yes No
	o. You smoked tobacco with him in the last 30 days.	  Yes No	  Yes No	  Yes No
	p. You drank alcohol with him in the last 30 days.	  Yes No	  Yes No	  Yes No
	q. You got drunk with him in the last 30 days.	  Yes No	  Yes No	  Yes No
	r. You used drugs with him in the last 30 days.	  Yes No	  Yes No	  Yes No

[Adapted from Add Health]

49.	Think of your closest female friends. List up to three of your closest female friends. List your best female friend first, then your next best friend, and so on. Include girls who are friends and girlfriends.
	Enter their initials, first name, or nick name:	Female Friend 1: _____	Female Friend 2: _____	Female Friend 3: _____
	If they are in school, what grade are they in? If they are NOT in school, how old are they?	Grade: Age: _____	Grade: Age: ____	Grade: Age: ____
	Fill in one circle under each friend:
	a. You went to her house in the last seven days when a parent was present.	  Yes No	  Yes No	  Yes No
	b. You went to her house in the last seven days without a parent present.	  Yes No	  Yes No	  Yes No
	c. She came to your house in the last seven days when a parent was present.	  Yes No	  Yes No	  Yes No
	d. She came to your house in the last seven days without a parent present.	  Yes No	  Yes No	  Yes No
	e. You met her after school or work to hang out or go somewhere in the last seven days.	  Yes No	  Yes No	  Yes No
	f. You spent time with her last weekend.	  Yes No	  Yes No	  Yes No
	g. You talked with her about a problem in the last seven days.	  Yes No	  Yes No	  Yes No
	h. You talked with her on the telephone in the last seven days.	  Yes No	  Yes No	  Yes No
	i. You emailed, text messaged, or twittered her in the last seven days.	  Yes No	  Yes No	  Yes No
	j. You and she are linked through your online network profile (‘friend’ on Facebook, ‘follower’ on Twitter).	  Yes No	  Yes No	  Yes No
	k. You exercised or played sports with her in the last seven days.	  Yes No	  Yes No	  Yes No
	l. You ate a meal with her in the last seven days.	  Yes No	  Yes No	  Yes No
	m. You played computer games with her in the last seven days.	  Yes No	  Yes No	  Yes No
	n. You watched television or videos/DVDs with her in the last seven days.	  Yes No	  Yes No	  Yes No
	o. You smoked tobacco with her in the last 30 days.	  Yes No	  Yes No	  Yes No
	p. You drank alcohol with her in the last 30 days.	  Yes No	  Yes No	  Yes No
	q. You got drunk with her in the last 30 days.	  Yes No	  Yes No	  Yes No
	r. You used drugs with her in the last 30 days.	  Yes No	  Yes No	  Yes No

50. Think of your closest male friend, your closest female friend, and your 5 closest friends that you spend time with. For each answer on a five-point scale: How often they do each of these things. 1 = never; 2 = almost never; 3 = sometimes; 4 = often; 5 = almost always Please mark one circle per friend:
	Closest male friend	Closest female friend	Five closest friends
Do vigorous physical activity at least 3 times a week	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Drink soda	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Drink alcohol	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Get drunk	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Smoke cigarettes	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Smoke/use marijuana	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Take other drugs	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Play computer games at least 2 hours every day	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Watch TV at least 2 hours every day	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
Spend free time with you in the afternoons or evenings hanging out without adults around	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 

Here are some questions about bullying. We say someone is BEING BULLIED when someone else, or a group of people, say or do nasty and unpleasant things to him or her. It is also bullying when someone is teased repeatedly in a way he or she does not like or when he or she is deliberately left out of things. But it is NOT BULLYING when two people of about the same strength or power argue or fight. It is also not bullying when someone is teased in a friendly and playful way.

51. (Please mark one circle for each line)	Never	Once or twice	2 or 3 times a month	About once a week	Several times a week
a. In the past couple of months, how often have you been bullied at school or work using a computer, e-mail messages or pictures?					
b. In the past couple of months, how often have you been bullied at school or work using a cell phone?					
c. In the past couple of months, how often have you bullied another student(s) or co-workerat school or work using a computer, e-mail messages or pictures?					
d. In the past couples of months, how often have you bullied another student(s) or co-workerat school or work using a cell phone?					

52. Which of the following best describes your sexual orientation?

 Attracted to opposite sex

 Attracted to same sex

 Attracted to both sexes

 Questioning

53. In the last 12 months, have you had a romantic relationship with anyone?

 No (skip to question 55)

 Yes Please write the number of romantic relationships in the last 12 months: __________

The following questions ask about things that might have happened in your romantic relationships over the last 12 months. Please think about your most recent relationship in the last 12 months. Don’t count anything you or your partner did it in self-defense.

54a.

Please enter the age of the partner in your most recent romantic relationship ___________
Enter their gender	 Male			 Female
Is this a current or past relationship?	 Current			 Past
How long have you been (or were you) together?	_________ years _________ months
How happy are (were) you in this relationship?	1  Not at all	2	3		4	5	6	7 Very Much
How important is (was) this relationship to you?	1  Not at all	2	3		4	5	6	7 Very Much

In the last 12 months,	This person did this to me					I did this to him/her
	Never	1-3 times	4-9 times	10 or more times		Never	1-3 times	4-9 times	10 or more times
Threatened to hurt me.					Threatened to hurt him/her.				
Would not let me do things with other people.					Would not let him/her do things with other people.				
Insulted me in front of others.					Insulted him/her in front of others.				
Hurt my feelings on purpose.					Hurt his/her feelings on purpose.				
Said mean things to me to make me feel bad about myself.					Said mean things to him/her to make him/her feel bad about his/her self.				

In the last 12 months,	This person did this to me					I did this to him/her
	Never	1-3 times	4-9 times	10 or more times		Never	1-3 times	4-9 times	10 or more times
Slapped or scratched me.					Slapped or scratched him/her.				
Physically twisted my arm or bent back my fingers.					Physically twisted his/her arm or bent back fingers.				
Pushed, grabbed, shoved, or kicked me.					Pushed, grabbed, shoved, or kicked him/her.				
Hit me with a fist or something else hard.					Hit him/her with a fist or something else hard.				
Assaulted me with a knife or gun.					Assaulted him/her with a knife or gun.				

In the last 12 months,	This person did this to me					I did this to him/her
	Never	1-3 times	4-9 times	10 or more times		Never	1-3 times	4-9 times	10 or more times
Kissed me when I did not want him/her to.					Kissed him/her when he/she did not want me to.				
Showed me pictures of naked people that I did not want to see.					Showed him/her pictures of naked people that he/she did not want to see.				
Showed me his/her private parts when I did not want him/her to.					Showed him/her my private parts when he/she did not want me to.				
Put his/her hand on one of my private parts when I did not want him/her to.					Put my hand on one of his/her private parts when he/she did not want me to.				
Forced me to have sex or do sexual things that I did not want to do.					Forced him/her to have sex or do sexual things that he/she did not want to do.				

The following questions ask about things done using a cell phone, e-mail, IM, text messaging, Web chat, a blog, or a networking site like MySpace or Facebook.

In the last 12 months,	This person did this to me					I did this to him/her
Using one of these technologies…	Never	1-3 times	4-9 times	10 or more times	Using one of these technologies…	Never	1-3 times	4-9 times	10 or more times
Spread rumors about me.					Spread rumors about him/her.				
Called me names, put me down, or said something really mean.					Called him/her names, put him/her down, or said something really mean.				
Showed private or embarrassing pictures/videos of me to others.					Showed private or embarrassing pictures/videos of him/her to others.				
Repeatedly checked up on me to see where I was.					Repeatedly checked up on him/her to see where he/she was.				

54b.

For the next questions, think about from when you first met until now, that is, the ENTIRE TIME you have been (or were) together with this person.

How often	Never	1-2 times	3-5 times	6 or more times	How often	Never	1-2 times	3-5 times	6 or more times
Has this person hit you out of self-defense?					Have you hit this romantic partner out of self-defense?				
Because of things this person did to you on purpose					Because of things you did to this person on purpose
Have you been injured (e.g. a bruise, a cut, a burn, a broken bone)?					Has he/she been injured (e.g. a bruise, a cut, a burn, a broken bone)?				
Have you had an injury that had to be treated by a doctor or nurse?					Has he/she had an injury that had to be treated by a doctor or nurse?				

Now think about your second most recent romantic relationship in the last 12 months. Remember, don’t count anything you or your partner did it in self-defense. If you only had ONE relationship in the last 12 months, please skip to Question 55.

54c.

Please enter the age of the partner in your second romantic relationship___________
Enter their gender	 Male			 Female
Is this a current or past relationship?	 Current			 Past
How long have you been (or were you) together?	_________years _________months
How happy are (were) you in this relationship?	Not at all 1 	2	3		4	5	6	Very Much 7
How important is (was) this relationship to you?	Not at all 1 	2	3		4	5	6	Very Much 7

In the last 12 months,	This person did this to me					I did this to him/her
	Never	1-3 times	4-9 times	10 or more times		Never	1-3 times	4-9 times	10 or more times
Threatened to hurt me.					Threatened to hurt him/her.				
Would not let me do things with other people.					Would not let him/her do things with other people.				
Insulted me in front of others.					Insulted him/her in front of others.				
Hurt my feelings on purpose.					Hurt his/her feelings on purpose.				
Said mean things to me to make me feel bad about myself.					Said mean things to him/her to make him/her feel bad about his/her self.				

In the last 12 months,	This person did this to me					I did this to him/her
	Never	1-3 times	4-9 times	10 or more times		Never	1-3 times	4-9 times	10 or more times
Slapped or scratched me.					Slapped or scratched him/her.				
Physically twisted my arm or bent back my fingers.					Physically twisted his/her arm or bent back fingers.				
Pushed, grabbed, shoved, or kicked me.					Pushed, grabbed, shoved, or kicked him/her.				
Hit me with a fist or something else hard.					Hit him/her with a fist or something else hard.				
Assaulted me with a knife or gun.					Assaulted him/her with a knife or gun.				

In the last 12 months,	This person did this to me					I did this to him/her
	Never	1-3 times	4-9 times	10 or more times		Never	1-3 times	4-9 times	10 or more times
Kissed me when I did not want him/her to.					Kissed him/her when he/she did not want me to.				
Showed me pictures of naked people that I did not want to see.					Showed him/her pictures of naked people that he/she did not want to see.				
Showed me his/her private parts when I did not want him/her to.					Showed him/her my private parts when he/she did not want me to.				
Put his/her hand on one of my private parts when I did not want him/her to.					Put my hand on one of his/her private parts when he/she did not want me to.				
Forced me to do have sex or do sexual things that I did not want to do.					Forced him/her to do sexual things that he/she did not want to do.				

The following questions ask about things done using a cell phone, e-mail, IM, text messaging, Web chat, a blog, or a networking site like MySpace or Facebook.

In the last 12 months,	This person did this to me					I did this to him/her
Using one of these technologies…	Never	1-3 times	4-9 times	10 or more times	Using one of these technologies…	Never	1-3 times	4-9 times	10 or more times
Spread rumors about me.					Spread rumors about him/her.				
Called me names, put me down, or said something really mean.					Called him/her names, put him/her down, or said something really mean.				
Showed private or embarrassing pictures/videos of me to others.					Showed private or embarrassing pictures/videos of him/her to others.				
Repeatedly checked up on me to see where I was.					Repeatedly checked up on him/her to see where he/she was.				

54d.

For the next questions, think about from when you first met until now, that is, the ENTIRE TIME you have been (or were) together with this person.

How often	Never	1-2 times	3-5 times	6 or more times	How often	Never	1-2 times	3-5 times	6 or more times
Has this person hit you out of self-defense?					Have you hit this romantic partner out of self-defense?				
Because of things person did to you on purpose					Because of things you did to this person on purpose
Have you been injured (e.g. a bruise, a cut, a burn, a broken bone)?					Has he/she been injured (e.g. a bruise, a cut, a burn, a broken bone)?				
Have you had an injury that had to be treated by a doctor or nurse?					Has he/she had an injury that had to be treated by a doctor or nurse?				

Different people have different reasons for deciding whether or not to do things. We want to know how true each of these reasons is for you.

For the next question, please mark one circle for each line on a scale from 1 to 7 where 1 means Not at all True and 7 means Very True.

55.	I treat my romantic partner the way I do because:
		Not at all True			Somewhat True			Very True
		1	2	3	4	5	6	7
	It fits with who I am							
	It makes me feel good							
	My friends will like me better							
	I feel pressured to							
	It is personally important to me							
	My partner lets me							

56.	At present, how often do you drink anything alcoholic, such as beer, wine, or hard liquor like vodka or rum? Throughout these questions, by a “drink,” we mean a can or bottle of beer, a glass of wine or a wine cooler, a shot of liquor, or a mixed drink with liquor in it. Please do not include any time when you only had a sip or two from a drink. (Please mark one circle for each line)
		Every day	Every week	Every month	Rarely	Never
	Beer					
	Wine					
	Liquor/Spirits (for example, gin, vodka)					
	Pre-mixed drinks (for example, Smirnoff Ice, Bacardi Breezer, Mike's Hard Lemonade)					
	Any other drink that contains alcohol					

57.	Think about the first time you had a drink of an alcoholic beverage. How old were you the first time you had a drink of an alcoholic beverage? Please do not include any time when you only had a sip or two from a drink. (If there is something you have not done, choose the ‘never’ category)
	 Never	I was		years old
		(Write in the box how old you were )
	Now think about the first time you drank 5 or more drinks on a single occasion.
	 Never	I was		years old
		(Write in the box how old you were )
	Now think about the first time you got drunk.
	 Never	I was		years old
		(Write in the box how old you were )

58.	On how many occasions (if any) have you done the following things in the LAST 30 DAYS? (Please mark one circle for each line)
		Never	Once or twice	3 - 5 times	6 - 9 times	10 - 19 times	20 - 39 times	40 times or more
	Smoked cigarettes							
	Drank alcohol							
	Been drunk							
	Blacked out when drinking alcohol							
	Used marijuana							

SOURCE: ESPAD

59. FOR BOYS

Think back again over the LAST 30 DAYS. How many times (if any) have you had five or more drinks IN A ROW ON AN OCCASION?

FOR GIRLS

Think back again over the LAST 30 DAYS. How many times (if any) have you had four or more drinks IN A ROW ON AN OCCASION?

 None

 1

 2

 3–5

 6–9

 10 or more times

YRBS

60. FOR BOYS

Think back again over the LAST 30 DAYS. How many times (if any) have you had five or more drinks IN A ROW WITHIN TWO HOURS?

FOR GIRLS

Think back again over the LAST 30 DAYS. How many times (if any) have you had four or more drinks IN A ROW WITHIN TWO HOURS?

 None

 1

 2

 3–5

 6–9

 10 or more times

61. Think of that last time you drank alcohol. Where were you when you drank?

 I never drink alcohol

 At home

 At someone else's home

 Out on the street, in a park, beach or other open area

 At a bar or a pub

 In a club

 In a restaurant

 Other places (please describe)

__________________________

SOURCE: ESPAD (European School Survey Project on Alcohol & other Drugs, 1995); HBSC 2002 (items 1 & 2)

Different people have different reasons for deciding whether or not to do things. We want to know how true each of these reasons is for you.

For the next question, please mark one circle for each line on a scale from 1 to 7 where 1 means Not at all True and 7 means Very True.

62.	I decide whether or not to smoke tobacco, drink alcohol, or smoke marijuana because:
		Not at all True			Somewhat True			Very True
		1	2	3	4	5	6	7
	It fits with who I am							
	It makes me feel good							
	My friends will like me better							
	I feel like I have to							
	It is personally important to me							
	It depends on how easily I can get it							

Adapted from Ryan, R. M., & Connell, J. P. (1989). Perceived locus of causality and internalization: Examining reasons for acting in two domains. Journal of Personality and Social Psychology, 57, 749-761.

63.	Have you ever taken one or several of these drugs in the last 12 months? (Please mark one circle for each line)
		Never	Once or twice	3 - 5 times	6 - 9 times	10 - 19 times	20 - 39 times	40 times or more
	Marijuana							
	Ecstasy							
	Amphetamines (meth, ice, glass, speed)							
	Opiates (heroin, morphine, smack)							
	Medication to get high							
	Cocaine/crack cocaine							
	Glue or solvents							
	Baltok							
	LSD							
	Anabolic steroids							
	Other drug. Which one? ______________							

SOURCE: HBSC 2002

64. Do you have a driver’s license?

 No license of any sort [skip to Question 73].

 Permit to take the classroom component of driver education only [skip to Question 73].

 Permit allowing supervised practice driving with an instructor or licensed adult.

 License allowing independent, unsupervised driving (with or without temporary restrictions on late night driving, teen passengers, etc.).

65. How much of the time during the last 30 days have you had access to a vehicle that you can drive?

 None

 Some

 Most

 All

For questions 66, 68, 69 and 70, please fill in the number of days from 0 to 30. For question 67, please fill in the number of miles in whole numbers.

66. On how many of last 30 days did you drive a vehicle? _______

67. On average, about how many miles did you drive each day you drove? _______

68. On how many days in the last 30 days have you driven with 2 or more passengers in the vehicle? _______

69. On how many DAYS in the last 30 days have you done the following while driving? (Please enter a number between 0 and 30 in the lines below)

# of days

1. Answered a call on your cell phone? ________

2. Made a call on your cell phone? ________

3. Changed radio station? ________

4. Changed music on an MP3, CD or other device? ________

5. Read text messages? ________

6. Sent text messages? ________

7. Drank or eaten? ________

8. Programmed a navigation system? ________

9. Looked at maps or directions while driving? ________

70. On how many DAYS in the last 30 days have you done the following while driving? (Please enter a number between 0 and 30 in the lines below)

# of days

1. Exceeded the speed limit in residential or school zones? ________

2. Gone 10 -19 miles per hour over the speed limit? ________

3. Gone 20 or more miles per hour over the speed limit? ________

4. Purposely tailgated or followed another vehicle very closely? ________

5. Switched lanes to weave through slower traffic? ________

6. Changed lanes with very little room between vehicles? ________

7. Cut in front of a vehicle to turn? ________

8. Pulled out into traffic without waiting for a large space between vehicles? ________

9. Made an illegal U-turn? ________

10. Gone through an intersection when the light was yellow or just turning yellow? ________

11. Gone through an intersection when the light was red or just turning red? ________

12. Gone through a stop sign without stopping completely? ________

13. Changed lanes without signaling? ________

14. Played the radio very loudly? ________

15. Raced another vehicle, even just for a short distance? ________

16. Read, groomed, ate, or engaged in similar activities? ________

17. Drove in a way to show off to other people? ________

18. Not worn a seat belt? ________

19. Drove when sleepy or drowsy? ________

20. Drove after midnight? ________

21. Drove after drinking alcohol or using illegal drugs? ________

Checkpoints (OMB # 0925-0577; Expiration Date: 01/31/2010)

71. How often in the last 12 months have you driven a vehicle (motorcycle, car, truck, or SUV) in a street race?

 0 times

 1 time

 2 or more times

72. The last time you were a driver in a street race, how many passengers were in your vehicle?

 Not in a street race in the past year

 0

 1

 2

 3 or more

73. How often do you wear a seat belt when riding in a vehicle driven by someone else?

 Never

 Rarely

 Sometimes

 Most of the time

 Always

74. During the last 12 months, how many times did you ride in a car or other vehicle driven by someone else who had been drinking alcohol or using illegal drugs?

 0 times

 1 time

 2 or 3 times

 4 or 5 times

 6 or more times

75. How often in the last 12 months have you been a passenger in a vehicle in a street race?

 0 times

 1 time

 2 or more times

76. In the last 12 months, how often have you been involved in a motor vehicle accident?

 0 times (skip to question 77)

 1 time

 2 or more times

- How often did the motor vehicle accident(s) result in an injury?

 0 times

 1 time

 2 or more times

-When the accident(s) occurred, how often were you were riding in a vehicle driven by someone who had been drinking alcohol or using illegal drugs?

 0 times

 1 time

 2 or more times

-When the accident(s) occurred, how often were you were driving a vehicle when you had been drinking alcohol or using illegal drugs?

 0 times

 1 time

 2 or more times

YRBS

77. Which of the following best describes your current health insurance situation? (Mark all that apply)

 I have no health insurance

 I am covered by my parent’s insurance

 I get insurance through school or work

 I do not know what my health insurance is

 Other _________________

78. Where do you usually go when you are sick or need health care? (Mark all that apply)

 Never get sick or need health care

 Hospital-based clinic

 Hospital emergency room

 Community health center or clinic

 Health maintenance organization (HMO)

 Private doctor’s office

 School or college clinic

 Military hospital or clinic

 Clinic at work

 Some other place

79. Has there been any time in the past 12 months when you thought you should get medical care, but you did not?

 Yes

 No (skip to Question 82)

80. What kept you from seeing a health professional when you really needed to? (Mark all that apply)

 Didn’t know whom to go see

 Had no transportation

 No one available to go along

 Parent or guardian would not go

 Didn’t want parents to know

 Difficult to make appointment

 Afraid of what the doctor would say or do

 Thought the problem would go away

 Couldn’t pay

 Other ________________

81. In the past 12 months, did a health problem get worse because you did not get care when you thought you should?

 Yes

 No

82. How long ago did you last see your pediatrician, primary care doctor, or family physician to have a routine check-up?

 Within the past 3 months

 4 to 6 months ago

 7 to 9 months ago

 10 to 12 months ago

 Longer than 1 year ago but less than 2 years ago

 2 years ago or longer

 Never

83. At your last physical examination by a doctor or nurse…

a. Were you asked:
whether you drink alcohol?	 Yes	 No
whether you smoke?	 Yes	 No
whether you use drugs?	 Yes	 No
whether you exercise?	 Yes	 No
nutrition questions?	 Yes	 No
whether you are sexually active?	 Yes	 No
b. Were you given advice about the risks associated with:	 Yes	 No
drinking?	 Yes	 No
smoking?	 Yes	 No
using drugs?	 Yes	 No
not exercising?	 Yes	 No
a poor diet?	 Yes	 No
sexual behavior?	 Yes	 No

c. Were you given advice about:	 Yes	 No
reducing or stopping drinking?	 Yes	 No
reducing or stopping smoking?	 Yes	 No
reducing or stopping drug use?	 Yes	 No
increasing physical activity?	 Yes	 No
improving your diet?	 Yes	 No
avoiding pregnancy?	 Yes	 No
avoiding sexually transmitted diseases?	 Yes	 No

[Add Health]

84. In the past 12 months have you had a dental examination by a dentist or dental hygienist?

 Yes

 No

If no, how long ago did you last have a dental examination by a dentist or hygienist?

 Longer than 1 year ago but less than 2 years ago

 2 years ago or longer

 Never

[Add Health]

85. What do you think are the chances that you will live to age 35?

 Almost no chance

 Some chance, probably not

 A 50-50 chance

 A good chance

 Almost certain

[Add Health]

TODAY’S DATE
Month	Day
○ January	○ 0	○ 0
○ February	○ 1	○ 1
○ March	○ 2	○ 2
○ April	○ 3	○ 3
○ May		○ 4
○ June		○ 5
○ July		○ 6
○ August		○ 7
○ September		○ 8
○ October		○ 9

Thank You