Attachment 2A Peer Survey Hard Copy

OMB No:

P Expiration Date:

2013

Generation Health Study Survey

January 4, 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. A participant in our study has recruited you to help us by completing this survey. You have agreed to participate in this one-time survey. The information you give will be used to improve the health of young adults like you. 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.	How old are you? The example on left is completed for someone 19 years old. Using the columns on the right, please write in your age and fill in the circles for your age.

EXAMPLE Age in years			Your age In years
1	9
 0	 0		 0	 0
 1	 1		 1	 1
 2	 2		 2	2
 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

2.	Are you a male or a female?
		Male
		Female

3.	What do you consider your ethnicity to be?
		Hispanic or Latino
		Not Hispanic or Latino

4.	What do you consider your race to be? (Mark all that apply)
		Black or African American
		White
		Asian
		American Indian or Alaska Native
		Native Hawaiian or Other Pacific Islander

5.	Are you currently attending school or working? If YES, please indicate the name and location (town, state) of the school and/or job in the appropriate line below. If you work and attend school, please fill in all that are appropriate
	1	No, I am not attending school or working
	2	High School (write in below) ___________________________________________
	3	Technical/Vocational School (write in below) _________________________________
	4	Community College (write in below) ______________________________________
	5	College/University (write in below) _______________________________________
	6	Graduate School or Professional School (write in below) _______________________________________
	7	Place where you work (write in below) _______________________________________

The following questions are about your relationship with the person(s) who recruited you into this study. If you were recruited by more than one person currently in the NEXT study, please fill out the second set of questions for the two persons with whom you spend the most time.

6.	What is your current relationship to the person who recruited you into this study?
		Friend
		Romantic partner
		Spouse
		Relative; if so, please specify (e.g., brother, sister, cousin, aunt, grandparent) _____________________________

7.	How long have you known him/her? _____ Years _____ Months

8.	How happy are you with your relationship with him/her?
	Not at all 1 2 3 4 5 6 7 Very Much

9.	How important is this friendship/relationship to you?
	Not at all 1 2 3 4 5 6 7 Very Much

10.	How often do you see him/her?
		Less than once a year
		About once a year
		Every few months
		Once a month or so
		Once or twice a week
		Almost daily or daily
		You live together

11.	How often do you talk or communicate with him/her using a phone, e-mail, IM or text messaging?
		Less than once a year
		About once a year
		Every few months
		Once a month or so
		Once or twice a week
		Almost daily or daily

The following questions are about you.

12.	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

13.	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).

14.	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).

15.	Please indicate which of the items below best represent your current marital status:
		Married
		Divorced
		Separated
		Widow/widower
		Member of an unmarried couple
		Never married

We would like to know about the place(s) where you lived in the past 12 months.

16.

Please answer this question for the place where you lived all or MOST OF THE TIME in the past 12 months. Where did you live for all or most of the past 12 months?



Your parent’s home or another person’s home



Your own place (house, apartment, trailer, etc.)



Group housing (residence hall/dorm, barracks, group home, hospital, communal home, prison or correctional facility (skip to question 19)



Homeless – that is, you have no regular place to stay (skip to question 20)



Other, please specify ______________________________

17.	How many people live there? ______

18.

Please mark all the people who live there.



Parent(s), grandparent(s), or guardian(s)



Brother(s) and/or sister(s)



Other relatives (cousin, aunt, uncle, nephew, niece)



Spouse or romantic partner



Roommate(s) or housemates



Children



I live alone

19.

If you live in group housing, what kind of group housing are you living in?



Residence hall/dorm at a school



Fraternity or sorority house



Barracks in the armed services



Half-way house, social rehabilitation facility



Prison, correctional facility



Group home



Hospital, nursing home, physical rehabilitation facility



Communal home



Other, please specify _______________________________

20.	If you lived in more than one place in the last 12 months, please indicate the second place where you lived most often in the past 12 months.
			I live in the same place all year long (skip to question 24)
			Your parent’s home or another person’s home
			Your own place (house, apartment, trailer, etc.)
			Group housing (residence hall/dorm, barracks, group home, hospital, communal home, prison or correctional facility (skip to question 23)
			Homeless – that is, you have no regular place to stay (skip to question 24)
			Other, please specify ______________________________
21.		How many people live there? ______
22.		Please mark all the people who live there.
					Parent(s), grandparent(s), or guardian(s)
					Brother(s) and/or sister(s)
					Other relatives (cousin, aunt, uncle, nephew, niece)
					Spouse or romantic partner
					Roommate(s) or housemates
					Children
					I live alone
23.				If you live in group housing, what kind of group housing are you living in?
					Residence hall/dorm at a school
					Fraternity or sorority house
					Barracks in the armed services
					Half-way house, social rehabilitation facility
					Prison, correctional facility
					Group home
					Hospital, nursing home, physical rehabilitation facility
					Communal home
					Other, please specify _______________________________

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.

24.	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

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.

25.	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

The next questions ask about different physical activities you may do. When thinking about activities, include organized teams and leagues, pick-up games, and things you do on your own. Mark how frequently and vigorously you do the activity.
26. During the PAST YEAR, what was the average time PER WEEK that you engaged in the activity							How much of that time is vigorous activity (You are out of breath and sweat)
Activity	None	Less than 1 hour	1 -2 hours	3-4 hours	5-7 hours	8+ hours	None	Some	Most
Walking for exercise									
Walking to school/work									
Baseball/softball									
Basketball									
Football									
Soccer									
Volleyball									
Cheerleading, Gymnastics, Poms									
Other team sports: (ie. Wrestling, hockey, boxing, lacrosse, rugby)									
Biking									
Swimming/ Rowing									
Martial Arts									
Marching band, color guard, baton, drill team									
Running: track & field, jogging or running for exercise									
Dance									
Personal workout/ Fitness Training: (ie. Yoga, zumba, gym equipment, weight training)									
Skiing/ snowboarding/ skateboarding									
Tennis, squash, racquetball, paddle ball									
Work-related physical activity (ie. Construction, landscaping, busboy)									
Household-related physical activity (ie. Lawn mowing, yard work, vacuuming)									
Other									

27.

On a typical weekday, how many hours a day do you spend sitting (Please include total sitting time; for example, during meetings, during class, during work, at mealtimes, watching television, at a computer, etc.). The example on left is completed for someone who spends 12 hours a day sitting. Using the columns on the right, please write the number of hours you typically spend sitting and fill in the circles to show number of hours.

EXAMPLE: 12 hours per day sitting			Your hours per day sitting
1	2
 0	 0		 0	 0
 1	 1		 1	 1
 2	 2		 2	2
 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

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.

28.	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

29.	How often do you eat in a fast food restaurant or snack stand (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 -> 

Weight in pounds Example-–152 lbs.				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), 2001/02 (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), 2001/02 (mandatory).

32.	Are you currently trying to:
		Lose weight
		Stay the same weight
		Gain weight
		I am not trying to do anything about my weight

33.	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

34.	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

35.		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 37)

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

36.		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)

37.	Think about how you have been feeling over the last 7 days. (Please mark one circle for each line)
	How often has each of these been true?
		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

38.	How important is it to your close friends 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			Somewhat				Extremely
		1	2	3	4		5	6	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

39.	This question is about things you do with the person who recruited you to complete this survey. For each of the items below, please indicate whether you did each of these things with this person.
	Fill in one circle for each line:
	e. You met him/her after school or work to hang out or go somewhere in the last seven days.		Yes	No
	f. You spent time with him/her last weekend.		Yes	No
	g. You talked with him/her about a problem in the last seven days.		Yes	No
	h. You talked with him/her on the telephone in the last seven days.		Yes	No
	i. You emailed, text messaged, or twittered him/her in the last seven days.		Yes	No
	j. You and he are linked through your online network profile (‘friend’ on Facebook, ‘follower’ on Twitter).		Yes	No
	k. You exercised or played sports with him/her in the last seven days.		Yes	No
	l. You ate a meal with him/her in the last seven days.		Yes	No
	m. You played computer games with him/her in the last seven days.		Yes	No
	n. You watched television or videos/DVDs with him/her in the last seven days.		Yes	No
	o. You smoked tobacco with him/her in the last 30 days.		Yes	No
	p. You drank alcohol with him/her in the last 30 days.		Yes	No
	q. You got drunk with him/her in the last 30 days.		Yes	No
	r. You used drugs with him/her in the last 30 days.		Yes	No

40. 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. Please mark one circle per friend:
1 = never; 2 = almost never; 3 = sometimes; 4 = often; 5 = almost always
	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 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 in the	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 
afternoons or evenings hanging out without adults around	1 2 3 4 5 	1 2 3 4 5 	1 2 3 4 5 

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

42.	Which of the following best describes your sexual orientation?
		Attracted to opposite sex
		Attracted to same sex
		Attracted to both sexes
		Questioning

43.		In the last 12 months, have you had a romantic relationship with anyone?
		No (skip to question 45)
		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 in self-defense.

44a.

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?	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	Slapped or scratched him/her.	Never	1-3 times	4-9 times	10 or more times
Slapped or scratched me.					Physically twisted his/her arm or bent back fingers.				
Physically twisted my arm or bent back my fingers.					Pushed, grabbed, shoved, or kicked him/her.				
Pushed, grabbed, shoved, or kicked me.					Hit him/her with a fist or something else hard.				
Hit me with a fist or something else hard.					Assaulted him/her with a knife or gun.				
Assaulted me with a knife or gun.					Slapped or scratched him/her.				

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…					Using one of these technologies…
	Never	1-3 times	4-9 times	10 or more times		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.				

44b.

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 45.

44c.

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?	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	Slapped or scratched him/her.	Never	1-3 times	4-9 times	10 or more times
Slapped or scratched me.					Physically twisted his/her arm or bent back fingers.				
Physically twisted my arm or bent back my fingers.					Pushed, grabbed, shoved, or kicked him/her.				
Pushed, grabbed, shoved, or kicked me.					Hit him/her with a fist or something else hard.				
Hit me with a fist or something else hard.					Assaulted him/her with a knife or gun.				
Assaulted me with a knife or gun.					Slapped or scratched him/her.				

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…					Using one of these technologies…
	Never	1-3 times	4-9 times	10 or more times		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.				

44d.

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?				

45.	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					

46.	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

47.	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

48.	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

49.	Do you have a driver’s license?
		No license of any sort (skip to Question 57)
		Permit to take the classroom component of driver education only (skip to Question 57)
		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.).

50.	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.

		# of days
51.	On how many of last 30 days did you drive a vehicle?	_______
52.	On average, about how many miles did you drive each day you drove?	_______
53.	On how many days in the last 30 days have you driven with 2 or more passengers in the vehicle?	_______
54.	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
	Talked on a cell phone?	­­­_______
	Changed music on an MP3, CD, radio or other device?	_______
	Read text messages?	_______
	Wrote text messages?	_______
	Read (other than text messages)?	_______
	Wrote (other than text messages)?	_______
	Used an iPad or computer (except for listening to music)?	_______
	Ate food?	_______
	Looked in the mirror to put on makeup or fix hair?	_______
	Looked at maps or directions?	_______
	Took my eyes off the road while reaching for a phone?	_______
	Took my eyes off the road while reaching for an object other than a phone	_______
	Horsed around with passengers or other such activities?	_______

55.	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
	Exceeded the speed limit in residential or school zones?	­­­_______
	Drove 20 or more miles per hour over the speed limit?	_______
	Purposely tailgated or followed another vehicle very closely?	_______
	Switched lanes to weave through slower traffic?	_______
	Changed lanes with very little room between vehicles?	_______
	Cut in front of a vehicle to turn?	_______
	Pulled out into traffic without waiting for a large space between vehicles?	_______
	Made an illegal U-turn?	_______
	Went through an intersection when the light was yellow or just turning yellow?	_______
	Went through an intersection when the light was red or just turning red?	_______
	Went through a stop sign without stopping completely?	_______
	Changed lanes without signaling?	_______
	Drove after drinking alcohol?	_______
	Raced another vehicle, even just for a short distance?	_______
	Drove after using illegal drugs?	_______
	Drove in a way to show off to other people?	_______
	Drove without wearing a seat belt?	_______
	Drove 10 MPH over the speed limit?	_______
	Drove when sleepy or drowsy?	_______

56.	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

57.	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

58.	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

59.	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

60.	In the last 12 months, how often have you been involved in a motor vehicle accident?
		0 times (skip to question 61)
		1 time
		2 or more times
	-How often did the motor vehicle accident(s) result in an injury?
		Not in an accident in the past year
		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?
		Not in an accident in the past year
		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?
		Not in an accident in the past year
		0 times
		1 time
		2 or more times

61.	Are you employed?  Yes  No (if no, skip to question 62)
	Where do you work? (For example, at a hospital, bank, or restaurant or in the military) ___________________________________________________________
	Please write down exactly what job you do there (for example, are you a teacher, bus driver, or doctor, ect.) ___________________________________________________________
	How many hours a week do you usually work? _________________

62.	What is the highest grade of regular school you have completed?
		Less than high school diploma
		High school diploma
		GED
		Some college or technical school
		Associate’s degree
		Bachelor’s degree
		Graduate degree

Please answer the following questions for your mother and father or up to two primary guardians when living at home.

63.	What is the highest grade of regular school your mother has completed?
		Less than high school diploma
		High school diploma
		GED
		Some college or technical school
		Associate’s degree
		Bachelor’s degree
		Graduate degree

64.	What is the highest grade of regular school your father has completed?
		Less than high school diploma
		High school diploma
		GED
		Some college or technical school
		Associate’s degree
		Bachelor’s degree
		Graduate degree

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