YOUTH RISK BEHAVIOR SURVEY QUESTIONNAIRE


This survey is about health behavior. It has been developed so you can tell us what you do that may affect your health.
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. 
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.




Directions

o	Use a #2 pencil only.
o	Make dark marks.
o	Fill in a response by completely darkening the oval that corresponds to the letter for your answer.
o	To change your answer, erase completely.

1.	How old are you?
A.	17 years old or younger
B.	18 years old
C.	19 years old
D.	20 years oldor older

2.	What is your sex?
A.	Female
B.	Male

3.  	In what grade are you?

5.	How do you describe your health in general?
A.  	Excellent 
B. 	Very good 
C.  	Good 
D.  	Fair  
E. 	Poor
	 







The next 7 questions ask about personal safety and violence-related behaviors.

8.	How often do you wear a seat belt when riding in a car?
A.	Never
B.	Rarely
C.	Sometimes
D.	Most of the time
E.	Always

9.	When you ride a bicycle, how often do you wear a helmet?
A.	I do not ride a bicycle
B.	Never wear a helmet
C.	Rarely wear a helmet
D.	Sometimes wear a helmet
E.	Most of the time wear a helmet
F.	Always wear a helmet

10.	When you rollerblade or ride a skateboard, how often do you wear a helmet?
A.	I do not rollerblade or ride a skateboard
B.	Never wear a helmet
C.	Rarely wear a helmet
D.	Sometimes wear a helmet
E.	Most of the time wear a helmet
F.	Always wear a helmet

11.	Have you ever ridden in a car driven by someone who had been drinking alcohol?
A.	Yes
B.	No
C.	Not sure

12.	Have you ever carried a weapon, such as a gun, knife, or club?
A.	Yes
B.	No

13.	Have you ever been in a physical fight?
A.	Yes
B.	No

14.	Have you ever been in a physical fight in which you were hurt and had to be treated by a doctor or nurse?
A.	Yes
B.	No


The next 3 questions ask about attempted suicide.  Sometimes people feel so depressed about the future that they may 
consider attempting suicide or killing themselves.  

15.	Have you ever seriously thought about killing yourself?
A.	Yes
B.	No

16.	Have you ever made a plan about how you would kill yourself?
A.	Yes
B.	No

17.	Have you ever tried to kill yourself?
A.	Yes
B.	No

The next 8 questions ask about tobacco use.

18.	Have you ever tried cigarette smoking, even one or two puffs?
A.	Yes
B.	No

19.	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 years old
D.	10 years old
E.	11 years old
F.	12 years old
G.	13 years old
H.	14 years old or older

20.	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


21.	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

22.	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

23.	Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?
A.	Yes
B.	No

24.	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


25.	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 2 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.

26.	Have you ever had a drink of alcohol, other than a few sips?
A.	Yes
B.	No

27.	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 years old
D.	10 years old
E.	11 years old
F.	12 years old
G.	13 years old
H.	14 years old or older

The next 2 questions ask about marijuana use.  Marijuana also is called grass or pot. 

28.	Have you ever used marijuana?
A.	Yes
B.	No


29.	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 years old
D.	10 years old
E.	11 years old
F.	12 years old
G.	13 years old
H.	14 years old or older

The next 4 questions ask about other drug use.

30.	Have you ever used any form of cocaine, including powder, crack, or freebase?
A.	Yes
B.	No

31.	Have you ever sniffed glue, or breathed the contents of spray cans, or inhaled any paints or sprays to get high?
A.	Yes
B.	No

32.	Have you ever used steroids?
A.	Yes
B.	No

33.	Have you ever used a needle to inject any illegal drug into your body?
A.	Yes
B.	No

The next 4 questions ask about sexual intercourse.

34.	Have you ever had sexual intercourse?
A.	Yes
B.	No


35.	How old were you when you had sexual intercourse for the first time?
A.	I have never had sexual intercourse
B.	8 years old or younger
C.	9 years old
D.	10 years old
E.	11 years old
F.	12 years old
G.	13 years old
H.	14 years old or older

36.	With how many people have you ever had sexual intercourse?
A.	I have never had sexual intercourse
B.	1 person
C.	2 people
D.	3 people
E.	4 or more people

37.	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

The next 7 questions ask about body weight.

38.	How do you describe your weight?
A.	Very underweight
B.	Slightly underweight
C.	About the right weight
D.	Slightly overweight
E.	Very overweight

39.	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

40.	Have you ever exercised to lose weight or to keep from gaining weight?
A.	Yes
B.	No


41.	Have you ever eaten less food, fewer calories, or foods low in fat to lose weight or to keep from gaining weight?
A.	Yes
B.	No

42.	Have you ever gone without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?
A.	Yes
B.	No

43.	Have you ever taken 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

44.	Have you ever vomited or taken laxatives to lose weight or to keep from gaining weight?
A.	Yes
B.	No

The next 4 questions ask about physical activity.

45.	On how many of the past 7 days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities?
A.	0 days
B.	1 day
C.	2 days
D.	3 days
E.	4 days
F.	5 days
G.	6 days
H.	7 days


46.	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

47.	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

48.	Do you play on any sports teams?  (Include any teams run by your school or community groups.)
A.	Yes
B.	No

The next question asks about AIDS education.

49.	Have you ever been taught about AIDS or HIV infection in high school?
A.	Yes
B.	No
C.	Not sure

50.	Have you ever been taught about AIDS or HIV infection in first year college?
A.	Yes
B.	No
C.	Not sure






	This is the end of the survey.
	Thank you very much for your help.