2016 Questionnaire

N R P F S S Administrative Use Only Nebraska Risk & School Name: Protective Factor Student Survey School ID: School District: Year 2016 The purpose of this survey is to learn how students in our schools feel about their community, family, peers, and school. The survey also asks about health behaviors. - The survey is completely voluntary and anonymous. Do NOT put your name on the questionnaire. - This is not a test, so there are no right or wrong answers. We would like you to work quickly so you can finish. - All of the questions should be answered by completely filling in one of the answer spaces. If you do not find an answer that fits exactly, use the one that comes closest. If any question does not apply to you, or you are not sure what it means, just leave it blank. You can skip any question that you do not wish to answer. - Mark only one answer to each question unless instructed otherwise. About You Your Experiences at School 1 Are you: 6 Putting them together, what were your grades Male like last year ? (Mark the one best answer.) Female Mostly F's Mostly D's Mostly C's 2 How old are you? Mostly B's 12 or younger 16 Mostly A's 13 17 14 18 15 19 or older 7 How interesting are most of your courses to you? Very interesting and stimulating Quite interesting 3 What grade are you in? Fairly interesting 7th 10th Slightly dull 8th 11th Very dull 9th 12th 8 How important do you think the things you are learning in school are going to be for your later life? 4 Are you Hispanic or Latino? Yes (Hispanic or Latino) Very important Quite important No (Not Hispanic or Latino) Fairly important Slightly important 5 What is your race? (Select one or more.) Not at all important Black or African American 9 Now thinking back over the past year in school, how Asian often did you enjoy being in school? American Indian Never Native Hawaiian or other Pacific Islander Seldom Alaska Native Sometimes White Often Other Almost always Page 1 of 8 Strongly Strongly Not w rong at all Disagree Agree disagree agree A little bit w rong 10 My teachers notice Wrong when I am doing a 17 How wrong do you think it is for Very wrong good job and let me someone your age to: know about it. a. smoke cigarettes? 11 There are lots of use smokeless tobacco (for example, chances for students b. chew, snuff, plug, dipping tobacco, or in my school to get chewing tobacco)? involved in sports, clubs, and other drink beer, wine, or hard liquor (for school activities c. example, vodka, whiskey, or gin) regularly, outside of class. that is, at least once or twice a month? drive after drinking beer, wine, or hard 12 There are lots of d. chances for students liquor? in my school to talk e. smoke marijuana? with a teacher use prescription drugs without a doctor f. one-on-one. telling them to? 13 I feel safe at my use LSD, cocaine, amphetamines, or g. school. another illegal drug? 14 In my school, there is an adult (such as a counselor, teacher, Almost all (91-100%) or coach) who listens Most (71-90%) Half to most (51-70%) to me when I have 18 Now thinking about all the something to say. Some to half (31-50%) students in your grade at Some (11-30%) 15 In my school, there is your school , how many of Few (1-10%) an adult (such as a them do you think: None (0%) counselor, teacher, smoked cigarettes during or coach) who always a. the past 30 days ? wants me to do my drank beer, wine, or hard best. b. liquor during the past 30 days ? Your Feelings and Experiences smoked marijuana during c. About Substance Use the past 30 days ? used an illegal drug (not 17 or older d. including marijuana) during 16 15 the past 30 days ? 14 13 Great risk 12 19 How much do you think people risk Moderate risk 11 harming themselves (physically or Slight risk 16 How old were you 10 or younger in other ways) if they: No risk when you first: Never have smoke one or more packs of cigarettes smoked a cigarette, even a. a. per day? just a puff? are exposed to other people's cigarette b. had more than a sip or two smoke? of beer, wine, or hard liquor b. use smokeless tobacco (for example, (for example, vodka, c. chew, snuff, plug, dipping tobacco, or whiskey, or gin)? chewing tobacco) every day? began drinking alcoholic take one or two drinks of an alcoholic beverages regularly, that is, c. d. beverage (beer, wine, or hard liquor) at least once or twice a nearly every day? month? have five or more drinks of an alcoholic e. d. smoked marijuana? beverage once or twice a week? Page 2 of 8 Great risk 20 How much do you think people risk Moderate risk 27 During the past 12 months, how often have you been harming themselves (physically or Slight risk so worried about something that you could not sleep in other ways) if they: No risk well at night? a. try marijuana once or twice? Never b. smoke marijuana once or twice a week? Rarely use prescription drugs that are not Sometimes c. prescribed to them? Most of the time sniff glue, breathe the contents of an Always d. aerosol spray can, or inhale other gases or sprays in order to get high? 28 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? Your Feelings and Experiences in Other Parts of Your Life Yes No Strongly Strongly 29 During the past 12 months, did you ever seriously Disagree Agree disagree agree consider attempting suicide? 21 I think sometimes Yes it's okay to cheat No at school. 22 I think it's okay to 30 During the past 12 months, did you actually attempt take something suicide? without asking if you can get away Yes with it. No 23 It's all right to beat up people if they 31 During the past 12 months, did you hurt or injure start the fight. yourself on purpose without wanting to die? (For example, by cutting, burning, or bruising yourself on purpose.) 24 Have you ever belonged to a gang? Yes No, and don't want to No No, but would like to Yes, in the past but not now Yes, belong now 32 If you were depressed or felt suicidal, who is the first person you would go to for help? 25 In the past week, I have felt hopeful about the A counselor in school future. Another adult in school (such as a teacher or coach) Strongly disagree Your parents or caregivers Disagree Your friends Agree A counselor or program outside of school Strongly agree Another adult outside of school (such as a relative, clergy, or other family friend) 26 When I make plans, I am almost certain that I can I wouldn't go to anyone make them work. Strongly disagree Disagree Agree Strongly agree Page 3 of 8 Once or 33 During the past 12 months, how frequently have you been bullied by other Never Monthly Weekly Daily students in the following ways? twice Physically? (For example, being hit, pushed, shoved, slapped, kicked, or a. having property stolen) Verbally? (For example, being called names, teased, insulted, or b. threatened) Socially? (For example, being excluded from a group, or having gossip or c. rumors spread about you) Electronically? (For example, being threatened or embarrassed through d. e-mail, text messages, or social media) 34 During the past 12 months, did someone you were 37 During the past 30 days, on how many days did you use dating or going out with physically hurt you on an electronic vapor product? purpose? 0 days I did not date or go out with anyone during 1 or 2 days the past 12 months 3 to 5 days Yes 6 to 9 days No 10 to 19 days 20 to 30 days 35 During the past 12 months, how many times did someone you were dating or going out with purposely 38 Have you ever used smokeless tobacco (chew, snuff, try to control you or emotionally hurt you? (Count such plug, dipping tobacco, or chewing tobacco)? things as being told who you could and could not spend time with, being humiliated in front of others, or Yes being threatened if you did not do what they wanted.) No I did not date or go out with anyone during the past 12 months 39 How frequently have you used smokeless tobacco 0 times during the past 30 days? 1 time Never 2 or 3 times Once or twice 4 or 5 times Once or twice per week 6 or more times 3 to 5 times a week About once a day More than once a day Your Experiences with Tobacco, Alcohol, and Other Drugs 40 Have you ever smoked cigarettes? Remember, your answers are confidential. Yes No 36 Have you ever used an electronic vapor product (for example, e-cigarettes, e-cigars, e-pipes, vape pipes, 41 How frequently have you smoked cigarettes during vaping pens, e-hookahs, or hookah pens)? the past 30 days? Yes Not at all No Less than 1 cigarette per day 1 to 5 cigarettes per day About 1/2 pack per day About 1 pack per day About 1 1/2 packs per day 2 packs or more per day Page 4 of 8 42 If you smoked cigarettes during the past 30 days, where did you get them? (Mark "Yes" or "No" for Did not Yes No each.

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