Appendix E: High School Survey Instrument

1. How old are you:  12 years old or younger  13 years old  14 years old  15 years old  16 years old  17 years old  18 years old or older

2. What is your sex?  Male  Female

3. In what grade are you?  9th grade  10th grade  11th grade  12th grade

4. What is your race/ethnicity? (Select all that apply)  American Indian / Alaskan Native  Asian  Black / African-American  Hispanic / Latino  Native Hawaiian or Other Pacific Islander  White / Caucasian  Other (Please specify) ______

5. How tall are you without shoes on?

Feet: ______Inches: ______

6. How much do you weigh without shoes on?

Weight: ______

E - 1 The next four questions ask about safety.

7. When you rode a bicycle, rollerblades, skateboard or four-wheeler (ATV) during the past 12 months, how often did you wear a helmet?  I did not ride a bicycle, rollerblades, skateboard or four wheeler  Never wore a helmet  Rarely wore a helmet  Sometimes wore a helmet  Most of the time wore a helmet  Always wore a helmet

8. How often do you wear a seatbelt when driving or riding in a car?  Never  Rarely  Sometimes  Most of the time  Always

9. How often per week do you use your cell phone while driving?  I do not have my driver’s license  Never  Once or twice a week  3-5 times a week  6-10 times a week  More than 10 times a week

10. How often per week do you text while driving?  I do not have my driver’s license  Never  Once or twice a week  3-5 times a week  6-10 times a week  More than 10 times a week

11. During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who has been drinking alcohol?  0 times  1 time  2-3 times  4-5 times  6 or more times

12. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?  0 times  1 time  2-3 times  4-5 times  6 or more times

E - 2 The next questions ask about violence-related behaviors.

13. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club?  0 days  1 day  2-3 days  4-5 days  6 or more days

The next 3 questions ask about bullying. Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when 2 students of about the same strength or power argue or fight or tease each other in a friendly way.

14. During the past 12 months, have you ever been bullied?  Yes  No 15. Do you use any social networking sites, like Facebook, MySpace or Twitter?  Yes  No 16. How many times in the past 6 months have you been the victim of cyber-bullying (bullying through text message, Facebook, MySpace, or other websites)?  Never  Once  2-3 times  4-6 times  7-10 times  More than 10 times

17. During the past 12 months, how many times were you in a physical fight?  0 times  1 times  2-3 times  4-5 times  6-7 times  8-9 times  10-11 times  12 or more times

18. 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?  0 times  1 time  2-3 times  4-5 times  6 or more times

E - 3 19. During the past 12 months, did your boyfriend or girlfriend ever hit, slap or physically hurt you on purpose?  Yes  No

20. Have you ever been physically forced to have sexual intercourse when you did not want to?  Yes  No

The next questions will ask about tobacco use.

21. Have you ever tried cigarette smoking, even one or two puffs?  Yes  No

22. Does anyone in your household smoke cigarettes?  Yes  No

23. How old were you when you smoked a whole cigarette for the first time?  I have never smoked a whole cigarette  8 years old or younger  9-10 years old  11-12 years old  13-14 years old  15-16 years old  17 years of age or older

24. During the past 30 days, on how many days did you smoke cigarettes?  0 days  1-2 days  3-5 days  6-9 days  10-19 days  20-29 days  All 30 days

25. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?  I did not smoke cigarettes during the past 30 days  Less than 1 cigarette per day  1 cigarette per day  2-5 cigarettes per day  6-10 cigarettes per day  11-20 cigarettes per day  More than 20 cigarettes per day

E - 4 26. During the past 30 days, how did you usually get your own cigarettes? (Select only one response)  I did not smoke cigarettes during the past 30 days  I bought them in a store, such as a convenience store, supermarket, discount store or gas station  I bought them from a vending machine  I gave someone else money to buy them for me  I borrowed (or bummed) them from someone else  My parents bought them for me  Another person 18 years old or older gave them to me  I took them from a store or family member  I got them some other way (Please specify ______)

27. Have you smoked cigarettes daily, that is, at least one cigarette every day for 30 days?  Yes  No

28. During the past 12 months, did you ever try to quit smoking cigarettes?  I did not smoke during the past 12 months  Yes  No

29. 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?  0 days  1-2 days  3-5 days  6-9 days  10-19 days  20-29 days  All 30 days

30. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?  0 days  1-2 days  3-5 days  6-9 days  10-19 days  20-29 days  All 30 days

E - 5 The next 10 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.

31. During your life, on how many days have you had at least one drink of alcohol?  0 days  1-2 days  3-9 days  10-19 days  20-39 days  40-99 days  100 or more days

32. How old were you when you had your first drink of alcohol other than a few sips?  I have never had a drink of alcohol other than a few sips  8 years old or younger  9-10 years old  11-12 years old  13-14 years old  15-16 years old  17 years old or older

33. During the past 30 days, on how many days did you have at least one drink of alcohol?  0 days  1-2 days  3-5 days  6-9 days  10-19 days  20-29 days  All 30 days

34. 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?  0 days  1-2 days  3-5 days  6-9 days  10-19 days  20-29 days  All 30 days

E - 6 35. During the past 30 days, how did you usually get the alcohol you drank?  I did not drink alcohol during the past 30 days  I bought it in a store, such as a liquor store, convenience store, supermarket, discount store, or gas station  I bought it at a restaurant, bar or club  I bought it at a public event, such as a concert or sporting event  I gave someone else money to buy it for me  A parent bought it for me  Someone gave it to me  I took it from a store or family member  I got it some other way (Please specify ______)

The next questions ask about drug use.

36. Has anyone ever tried to sell or give you an illegal drug?  Yes  No

37. During your life, how many times have you used marijuana? (Also called grass or pot)  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40-99 times  100 or more times

38. How old were you when you tried marijuana for the first time?  I have never tried marijuana  8 years old or younger  9-10 years old  11-12 years old  13-14 years old  15-16 years old  17 years of age or older

39. During the past 30 days, how many times did you use marijuana?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

E - 7 40. During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

41. During the past 30 days, how many times did you use any form of cocaine, including powder, crack or free base?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

42. During your life, how many times have you sniffed glue, breathed the content of aerosol spray cans, or inhaled any paints or sprays to get high?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

43. During your life, how many times have you used heroin (also called smack, junk, or China White)?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

44. During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice)?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

E - 8 45. During your life, how many times have you used ecstasy (also called MDMA)?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

46. During your life, how many times have you taken steroid pills or shots without a doctor’s prescription?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

47. During your life, how many times have you used a needle to inject any illegal drug into your body?  0 times  1 time  2 or more times

48. During your life, how many times have you taken prescription drugs that were not prescribed to you in order to get high?  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 or more times

49. How did you get the prescription pills that you took in order to get high?  I have never used prescription pills in order to get high  I took them from my medicine cabinet without my parent’s knowledge  My parents gave them to me  A friend gave them to me  I stole them from a store, such as a pharmacy, convenient store, or grocery store  I got it some other way (Please specify ______)

The next questions will ask about perceptions of drug and alcohol use.

50. How much do you think people risk harming themselves (physically or in other ways) if they smoke cigarettes?  No risk  Slight risk  Moderate risk  Great risk

E - 9 51. How much do you think people risk harming themselves (physically or in other ways) if they smoke marijuana?  No risk  Slight risk  Moderate risk  Great risk

52. How much do you think people risk harming themselves (physically or in other ways) if they drink alcohol? (Like beer, wine, or hard liquors such as vodka, whiskey, or gin)  No risk  Slight risk  Moderate risk  Great risk

53. How do you think your parents or guardians would feel about you smoking cigarettes?  Would approve  Would not care  Disapprove some  Strongly disapprove

54. How do you think your parents or guardians would feel about you smoking marijuana?  Would approve  Would not care  Disapprove some  Strongly disapprove

55. How do you think your parents or guardians would feel about you drink alcohol? (Like beer, wine, or hard liquors such as vodka, whiskey, or gin)  Would approve  Would not care  Disapprove some  Strongly disapprove

The next questions will ask about sexual behavior.

56. Do you plan to abstain from sexual activity until marriage?  Yes  No

57. Have you ever sent or received sexually explicit pictures or video on your cell phone of yourself or another person (also known as sexting)?  Yes  No

E - 10 The next questions will ask about body weight.

58. How do you describe your weight?  Very underweight  Slightly underweight  About the right weight  Slightly overweight  Very overweight

59. Which of the following are you trying to do about your weight?  Lose weight  Gain weight  Stay the same weight  I am not trying to do anything about my weight

60. During the past 30 days, did you exercise to lose weight or to keep from gaining weight?  Yes  No

61. During the past 30 days, did you eat less food, fewer calories, fewer carbs, or foods low in fat to lose weight or to keep from gaining weight?  Yes  No

62. 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?  Yes  No

63. 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.)  Yes  No

64. During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?  Yes  No

The next questions will ask about food you ate or drank during the past 7 days. Think about all the meals and snacks you had from the time you got up until you went to bed. Be sure to include food you ate at home, at school, at restaurants, or anywhere else.

E - 11 65. During the past 7 days, how many times did you drink 100% fruit juices such as orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid, sports drinks, or other fruit-flavored drinks)  I did not drink 100% fruit juice during the past 7 days  1-3 times during the past 7 days  4-6 times during the past 7 days  1 time per day  2 times per day  3 times per day  4 or more times per day

66. During the past 7 days, how many times did you eat fruit? (Do not count fruit juice)  I did not eat fruit during the past 7 days  1-3 times during the past 7 days  4-6 times during the past 7 days  1 time per day  2 times per day  3 times per day  4 or more times per day

67. During the past 7 days, how many times did you eat vegetables? (such as salads, carrots, or other vegetables)  I did not eat vegetables during the past 7 days  1-3 times during the past 7 days  4-6 times during the past 7 days  1 time per day  2 times per day  3 times per day  4 or more times per day

68. During the past 7 days, how many times did you eat potatoes? (Do not count french fries, fried potatoes, or potato chips.)  I did not eat potatoes during the past 7 days  1-3 times during the past 7 days  4-6 times during the past 7 days  1 time per day  2 times per day  3 times per day  4 or more times per day

69. During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not include diet soda or diet pop.)  I did not drink soda or pop during the past 7 days  1-3 times during the past 7 days  4-6 times during the past 7 days  1 time per day  2 times per day  3 times per day  4 or more times per day

E - 12 70. During the past 7 days, how many glasses of milk did you drink? (Include the milk you drank in a glass or cup, from a carton, or with cereal. Count the half pint of milk served at school as equal to one glass.)  I did not drink milk during the past 7 days  1-3 glasses during the past 7 days  4-6 glasses during the past 7 days  1 glass per day  2 glasses per day  3 glasses per day  4 or more glasses per day

71. During the past 7 days, how many times did you drink an energy drink, such as Red Bull, Monster, or Five Hour Energy?  I did not drink an energy drink during the past 7 days  1-3 glasses during the past 7 days  4-6 glasses during the past 7 days  1 glass per day  2 glasses per day  3 glasses per day  4 or more glasses per day

The next questions will 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 spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)  0 days  1 day  2 days  3 days  4 days  5 days  6 days  7 days

73. On an average school day, how many hours do you watch TV?  I do not watch TV on an average school day  Less than 1 hour per day  1 hour per day  2 hours per day  3 hours per day  4 hours per day  5 or more hours per day

E - 13 74. On an average school day, how many hours do you play video or computers 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)  I do not play video or computer games or use a computer for something that is not school work  Less than 1 hour per day  1 hour per day  2 hours per day  3 hours per day  4 hours per day  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?  0 days  1 day  2 days  3 days  4 days  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)  0 teams  1 team  2 teams  3 or more teams

The next questions will ask about mental health.

77. During the past 12 months, have you ever had a hard time concentrating on completing a task?  Yes  No

78. 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?  Yes  No

79. During the past 12 months, did you ever seriously consider attempting suicide?  Yes  No

80. During the past 12 months, how many times did you actually attempt suicide?  0 times  1 time  2-3 times  4-5 times  6 or more times

E - 14 81. 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?  Yes  No  Did not attempt suicide during the past 12 months

82. When you feel sad, hopeless, or depressed, with whom do you talk about your concerns? (Select all that apply)  No one  Best friend  My girlfriend/boyfriend  Pastor/priest  Brother/sister  Parents  Youth minister  Scout master  Teacher  School counselor  Professional counselor  Other (Please Specify______)

83. During your life, how many times have you purposely hurt yourself? (for example, cutting, burning, scratching, hitting, biting, etc)  0 times  1-2 times  3-9 times  10-19 times  20-39 times  40 times or more

The next questions will ask about other health-related topics.

84. Have you ever been taught about AIDS or HIV infection in school?  Yes  No  Not sure

85. Has a doctor or nurse ever told you that you have asthma?  Yes  No  Not sure

86. Do you still have asthma?  I have never had asthma  Yes  No  Not sure

E - 15 87. How long has it been since you last visited the dentist for any reason?  Never  Less than 1 year ago  1 year, but less than 2 years ago  2 years, but less than 5 years ago  5 or more years ago

88. Outside of school, what kinds of things do you do for fun in Darke County? (Open-ended Question)

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