Student Health Survey
Study to Examine Web-based Administration of the Youth Risk Behavior Survey
Appendix E1 - Student Health Survey Without Skips
Student Health Survey
OMB: 0920-0763
Appendix E1. Data Collection Instrument for Students – “Student Health Survey”
Form Approved OMB
No.: 0920-xxxx
Expiration
Date: xx/xx/xx
Student Health Survey
This survey is about health behavior. It has been developed so you can tell us what you do that may affect your health. It will also ask you questions about your experience taking this survey. The information you give will be used to develop better health education for young people like yourself.
DO NOT write your name on this survey. The answers you give will be kept private. No one will know what you write. Answer the questions based on what you really do.
Completing the survey is voluntary. Whether or not you answer the questions will not affect your grade in this class. If you are not comfortable answering a question, just leave it blank.
The questions that ask about your background will be used only to describe the types of students completing this survey. The information will not be used to find out your name. No names will ever be reported.
Make sure to read every question. Fill in the ovals completely. When you are finished, follow the instructions of the person giving you the survey.
Thank you very much for your help.
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-XXXX).
DIRECTIONS
Use a #2 pencil only.
M
ake
dark marks.Fill in a response like this: A B C D
If you change your answer, erase your old answer completely.
1. How old are you?
A
. 12
years old or younger
B. 13 years old
C. 14 years old
D. 15 years old
E. 16 years old
F. 17 years old
G. 18 years old or older
2. What is your sex?
A
. Female
B. Male
3. In what grade are you?
A
. 9th
grade
B
. 10th
grade
C
. 11th
grade
D. 12th grade
E. Ungraded or other grade
4. Are you Hispanic or Latino?
A
. Yes
B. No
5. What is your race? (Select one or more responses.)
A
. American
Indian or Alaska Native
B
. Asian
C. Black or African American
D. Native Hawaiian or Other Pacific Islander
E. White
6. How tall are you without your shoes on?
Directions: Write your height in the shaded blank boxes. Fill in the matching oval below each number.
Example
-
Height
Height
Feet
Inches
Feet
Inches
5
7
3
0
3
0
4
1
4
1
5
2
5
2
6
3
6
3
7
4
7
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
7. How much do you weigh without your shoes on?
Directions: Write your weight in the shaded blank boxes. Fill in the matching oval below each number.
Example
-
Weight
Weight
Pounds
Pounds
1
5
2
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
5
5
5
5
6
6
6
6
7
7
7
7
8
8
8
8
9
9
9
9
The next 4 questions ask about safety.
8. When you rode a bicycle during the past 12 months, how often did you wear a helmet?
A
. I
did not ride a bicycle during the past 12 months
B
. Never
wore a helmet
C. Rarely wore a helmet
D
. Sometimes
wore a helmet
E. Most of the time wore a helmet
F
. Always
wore a helmet
9. How often do you wear a seat belt when riding in a car driven by someone else?
A
. Never
B. Rarely
C
. Sometimes
D. Most of the time
E
. Always
10. During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol?
A
. 0
times
B. 1 time
C
. 2
or 3 times
D. 4 or 5 times
E
. 6
or more times
11. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?
A
. 0
times
B. 1 time
C
. 2
or 3 times
D. 4 or 5 times
E
. 6
or more times
The next 11 questions ask about violence-related behaviors.
12. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club?
A
. 0
days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
13. During the past 30 days, on how many days did you carry a gun?
A
. 0
days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
14. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club on school property?
A
. 0
days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
15. During the past 30 days, on how many days did you not go to school because you felt you would be unsafe at school or on your way to or from school?
A
. 0
days
B. 1 day
C. 2 or 3 days
D. 4 or 5 days
E. 6 or more days
16. During the past 12 months, how many times has someone threatened or injured you with a weapon such as a gun, knife, or club on school property?
A
. 0
times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or 7 times
F
. 8
or 9 times
G. 10 or 11 times
H. 12 or more times
17. During the past 12 months, how many times has someone stolen or deliberately damaged your property such as your car, clothing, or books on school property?
A
. 0
times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or 7 times
F
. 8
or 9 times
G. 10 or 11 times
H
. 12
or more times
18. During the past 12 months, how many times were you in a physical fight?
A
. 0
times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or 7 times
F
. 8
or 9 times
G. 10 or 11 times
H
. 12
or more times
19. During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?
A
. 0
times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
20. During the past 12 months, how many times were you in a physical fight on school property?
A
. 0
times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or 7 times
F
. 8
or 9 times
G. 10 or 11 times
H
. 12
or more times
21. During the past 12 months, did your boyfriend or girlfriend ever hit, slap, or physically hurt you on purpose?
A
. Yes
B. No
22. Have you ever been physically forced to have sexual intercourse when you did not want to?
A
. Yes
B. No
The next 5 questions ask about sad feelings and attempted suicide. Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life.
23. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?
A
. Yes
B. No
24. During the past 12 months, did you ever seriously consider attempting suicide?
A
. Yes
B. No
25. During the past 12 months, did you make a plan about how you would attempt suicide?
A
. Yes
B. No
26. During the past 12 months, how many times did you actually attempt suicide?
A
. 0
times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or more times
27. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?
A
. I
did not attempt suicide during the past 12 months
B. Yes
C. No
The next 11
questions ask about tobacco use.
28. Have you ever tried cigarette smoking, even one or two puffs?
A
. Yes
B. No
29. How old were you when you smoked a whole cigarette for the first time?
A
. I
have never smoked a whole cigarette
B
. 8
years old or younger
C. 9 or 10 years old
D
. 11
or 12 years old
E. 13 or 14 years old
F
. 15
or 16 years old
G
. 17
years old or older
30. During the past 30 days, on how many days did you smoke cigarettes?
A
. 0
days
B
. 1
or 2 days
C
. 3
to 5 days
D
. 6
to 9 days
E
. 10
to 19 days
F
. 20
to 29 days
G
. All
30 days
31. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
A
. I
did not smoke cigarettes during the past 30 days
B
. Less
than 1 cigarette per day
C
. 1
cigarette per day
D. 2 to 5 cigarettes per day
E. 6 to 10 cigarettes per day
F. 11 to 20 cigarettes per day
G. More than 20 cigarettes per day
32. During the past 30 days, how did you usually get your own cigarettes? (Select only one response.)
A
. I
did not smoke cigarettes during the past 30 days
B
. I
bought them in a store such as a convenience store, supermarket,
discount store, or gas station
C. I bought them from a vending machine
D. I gave someone else money to buy them for me
E. I borrowed (or bummed) them from someone else
F. A person 18 years old or older gave them to me
G
. I
took them from a store or family member
H
. I
got them some other way
33. During the past 30 days, on how many days did you smoke cigarettes on school property?
A
. 0
days
B. 1 or 2 days
C. 3 to 5 days
D. 6 to 9 days
E. 10 to 19 days
F
. 20
to 29 days
G
. All
30 days
34. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?
A
. Yes
B. No
35. During the past 12 months, did you ever try to quit smoking cigarettes?
A
. I
did not smoke during the past 12 months
B
. Yes
C. No
36. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?
A
. 0
days
B
. 1
or 2 days
C
. 3
to 5 days
D
. 6
to 9 days
E
. 10
to 19 days
F
. 20
to 29 days
G
. All
30 days
37. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip on school property?
A
. 0
days
B
. 1
or 2 days
C
. 3
to 5 days
D
. 6
to 9 days
E
. 10
to 19 days
F
. 20
to 29 days
G
. All
30 days
38. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
A
. 0
days
B
. 1
or 2 days
C
. 3
to 5 days
D
. 6
to 9 days
E
. 10
to 19 days
F
. 20
to 29 days
G
. All
30 days
The next 6 questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes.
39. During your life, on how many days have you had at least one drink of alcohol?
A
. 0
days
B
. 1
or 2 days
C
. 3
to 9 days
D
. 10
to 19 days
E
. 20
to 39 days
F
. 40
to 99 days
G
. 100
or more days
40. How old were you when you had your first drink of alcohol other than a few sips?
A
. I
have never had a drink of alcohol other than a few sips
B
. 8
years old or younger
C. 9 or 10 years old
D
. 11
or 12 years old
E. 13 or 14 years old
F
. 15
or 16 years old
G
. 17
years old or older
41. During the past 30 days, on how many days did you have at least one drink of alcohol?
A
. 0
days
B
. 1
or 2 days
C
. 3
to 5 days
D
. 6
to 9 days
E
. 10
to 19 days
F
. 20
to 29 days
G
. All
30 days
42. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?
A
. 0
days
B
. 1
day
C
. 2
days
D
. 3
to 5 days
E
. 6
to 9 days
F
. 10
to 19 days
G
. 20
or more days
43. During the past 30 days, how did you usually get the alcohol you drank?
A
. I
did not drink alcohol during the past 30 days
B
. I
bought it in a store such as a liquor store, convenience store,
supermarket, discount store, or gas station
C. I bought it at a restaurant, bar, or club
D. I bought it at a public event such as a concert or sporting event
E. I gave someone else money to buy it for me
F. Someone gave it to me
G
. I
took it from a store or family member
H
. I
got it some other way
44. During the past 30 days, on how many days did you have at least one drink of alcohol on school property?
A
. 0
days
B
. 1
or 2 days
C
. 3
to 5 days
D
. 6
to 9 days
E
. 10
to 19 days
F
. 20
to 29 days
G
. All
30 days
The next 4 questions ask about marijuana use. Marijuana also is called grass or pot.
45. During your life, how many times have you used marijuana?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
to 99 times
G
. 100
or more times
46. How old were you when you tried marijuana for the first time?
A
. I
have never tried marijuana
B
. 8
years old or younger
C. 9 or 10 years old
D
. 11
or 12 years old
E. 13 or 14 years old
F
. 15
or 16 years old
G
. 17
years old or older
47. During the past 30 days, how many times did you use marijuana?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
48. During the past 30 days, how many times did you use marijuana on school property?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
The next 9 questions ask about other drugs.
49. During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
50. During the past 30 days, how many times did you use any form of cocaine, including powder, crack, or freebase?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
51. During your life, how many times have you sniffed glue, breathed the contents of aerosol spray cans, or inhaled any paints or sprays to get high?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
52. During your life, how many times have you used heroin (also called smack, junk, or China White)?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
53. During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice)?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
54. During your life, how many times have you used ecstasy (also called MDMA)?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
55. During your life, how many times have you taken steroid pills or shots without a doctor's prescription?
A
. 0
times
B
. 1
or 2 times
C
. 3
to 9 times
D
. 10
to 19 times
E
. 20
to 39 times
F
. 40
or more times
56. During your life, how many times have you used a needle to inject any illegal drug into your body?
A
. 0
times
B
. 1
time
C
. 2
or more times
57. During the past 12 months, has anyone offered, sold, or given you an illegal drug on school property?
A
. Yes
B
. No
The next 7 questions ask about sexual behavior.
58. Have you ever had sexual intercourse?
A
. Yes
B
. No
59. How old were you when you had sexual intercourse for the first time?
A
. I
have never had sexual intercourse
B
. 11
years old or younger
C
. 12
years old
D. 13 years old
E. 14 years old
F. 15 years old
G. 16 years old
H
. 17
years old or older
60. During your life, with how many people have you had sexual intercourse?
A
. I
have never had sexual intercourse
B
. 1
person
C
. 2
people
D. 3 people
E. 4 people
F. 5 people
G. 6 or more people
61. During the past 3 months, with how many people did you have sexual intercourse?
A
. I
have never had sexual intercourse
B
. I
have had sexual intercourse, but not during the past 3 months
C
. 1
person
D. 2 people
E. 3 people
F. 4 people
G. 5 people
H
. 6
or more people
62. Did you drink alcohol or use drugs before you had sexual intercourse the last time?
A
. I
have never had sexual intercourse
B
. Yes
C
. No
63. The last time you had sexual intercourse, did you or your partner use a condom?
A
. I
have never had sexual intercourse
B
. Yes
C
. No
64. The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy? (Select only one response.)
A
. I
have never had sexual intercourse
B
. No
method was used to prevent pregnancy
C
. Birth
control pills
D. Condoms
E. Depo-Provera (injectable birth control)
F. Withdrawal
G. Some other method
H
. Not
sure
The next 7 questions ask about body weight.
65. How do you describe your weight?
A
. Very
underweight
B
. Slightly
underweight
C
. About
the right weight
D
. Slightly
overweight
E. Very overweight
66. Which of the following are you trying to do about your weight?
A
. Lose
weight
B
. Gain
weight
C. Stay the same weight
D. I am not trying to do anything about my weight
67. During the past 30 days, did you exercise to lose weight or to keep from gaining weight?
A
. Yes
B
. No
68. During the past 30 days, did you eat less food, fewer calories, or foods low in fat to lose weight or to keep from gaining weight?
A
. Yes
B
. No
69. During the past 30 days, did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?
A
. Yes
B
. No
70. During the past 30 days, did you take any diet pills, powders, or liquids without a doctor's advice to lose weight or to keep from gaining weight? (Do not include meal replacement products such as Slim Fast.)
A
. Yes
B
. No
71. During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?
A
. Yes
B
. No
The next 5 questions ask about physical activity.
72. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spend in any kind of physical activity that increases your heart rate and makes you breathe hard some of the time.)
A
. 0
days
B. 1 day
C
. 2
days
D. 3 days
E
. 4
days
F
. 5
days
G
. 6
days
H
. 7
days
73. On an average school day, how many hours do you watch TV?
A
. I
do not watch TV on an average school day
B
. Less
than 1 hour per day
C
. 1
hour per day
D. 2 hours per day
E. 3 hours per day
F. 4 hours per day
G. 5 or more hours per day
74. On an average school day, how many hours do you play video or computer games or use a computer for something that is not school work? (Include activities such as Nintendo, Game Boy, PlayStation, Xbox, computer games, and the Internet.)
A
. I
do not play video or computer games or use a computer for something
that is not school work
B
. Less
than 1 hour per day
C
. 1
hour per day
D
. 2
hours per day
E. 3 hours per day
F
. 4
hours per day
G. 5 or more hours per day
75. In an average week when you are in school, on how many days do you go to physical education (PE) classes?
A
. 0
days
B
. 1
day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
76. During the past 12 months, on how many sports teams did you play? (Include any teams run by your school or community groups.)
A
. 0
teams
B. 1 team
C. 2 teams
D. 3 or more teams
The next question asks about AIDS education.
Have you ever been taught about AIDS or HIV infection in school?
A
. Yes
B. No
C. No
sure
The next 2 questions ask about missing school.
78. During the past 30 days, on how many days did you miss classes or school for any reason, with or without permission?
A
. 0
days
B
. 1
day
C
. 2
or 3 days
D
. 4
or 5 days
E
. 6
to 9 days
F
. 10
or more days
79. During the past 30 days, on how many days did you miss classes or school without permission?
A
. 0
days
B
. 1
day
C
. 2
or 3 days
D
. 4
or 5 days
E
. 6
to 9 days
F
. 10
or more days
The next 2 questions ask about your experience using computers.
80. On an average school day, how many hours do you use a computer? Include activities such as being on the internet, playing computer games, sending e-mail, and doing homework.
A
. I
do not use a computer
B
. Less
than 1 hour per day
C
. 1
hour per day
D
. 2
hours per day
E. 3 hours per day
F
. 4
hours per day
G. 5 or more hours per day
*81. (Before today,) have you ever used a computer to take a survey or test?
A
. Yes
B. No
The next 3 questions ask about your experience taking this survey.
82. While taking this survey, could anyone besides you see your answers?
A
. Yes
B. No
C. No
sure
83. While taking this survey, did you ask anyone about what some questions meant or about what your answers should be?
A
. Yes
B. No
84. If you had a choice of taking this survey on the internet or taking this survey using paper and pencil, which would you choose?
A
. Internet
B
. Paper
and pencil
C
. It
would not matter to me
How much do you agree or disagree with the following 4 statements?
85. I am confident that the answers I gave in this survey will never be linked with my name.
A
. Strongly
agree
B
. Agree
C
. Neither
agree nor disagree
D
. Disagree
E. Strongly disagree
86. I wish I could have taken the survey in a more private place.
A
. Strongly
agree
B
. Agree
C
. Neither
agree nor disagree
D
. Disagree
E. Strongly disagree
*87. Taking this survey on the internet would keep (keeps) it from being private.
A
. Strongly
agree
B
. Agree
C
. Neither
agree nor disagree
D
. Disagree
E. Strongly disagree
88. I am concerned that people I do not know can get personal information about me when I am visiting websites on the internet.
A
. Strongly
agree
B
. Agree
C
. Neither
agree nor disagree
D
. Disagree
E. Strongly disagree
The following 3 (4) questions ask about how you took this survey.
89. How was your class originally asked to take this survey?
A.
On paper
B.
On a computer
C. Not sure
90. How was your class originally asked to do this survey?
A.
As a group in class
B.
Individually, on our own time
C. Not
sure
91. Did you take this survey at the same time as most of the other students in your class?
A.
Yes
B. No
C. Not
sure
9
2.
Which of the following best describes where you took this
survey?**
A. Computer lab at school
B
. At
school, but not in a computer lab
C
. Home
D
. Work
E. Friend’s house
F
. Public
place, such as a library or internet café
G. Somewhere else
*Question wording is for paper-and-pencil condition. Words in parentheses will be used for computer condition.
**Question will appear on web-based questionnaire only.
This is the end of the survey.
Thank you very much for your help.
| File Type | application/msword |
| File Title | Appendix D |
| Author | kflint |
| Last Modified By | arp5 |
| File Modified | 2007-09-17 |
| File Created | 2007-09-17 |
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