6
7
8
9
10
11
12
other
If not schooled: are you homeschooled or cyber schooled?
Homeschooled
Cyber schooled
Male
Female
Other
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
I live with 2 parents/guardians
I split time between 2 parents/guardians
I live with 1 parent/guardian
Yes, I have been physically bullied
Yes, I have been electronically bullied (through texting, Instagram, Facebook, or other social media)
Yes, I have been both physically and electronically bullied
No, I have never been bullied
Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again.
Do you have any chronic medical or psychiatric conditions?
Yes
No
What medical or psychiatric conditions do you have?
How often do you attend religious service?
At least 1/week
At least 1/month
Less frequent
None
Do you have a role model?
Yes
No
I don't know what that means
Do you have someone you look up to?
Yes
No
Yes
No
I don't know what that means
Is there anyone in your life that you can go to when you need help/advice?
Yes
No
Yes
No
I don't know what that means
Is there a person you admire or idolize for their courage, outstanding achievements, or noble qualities?
Yes
No
How would you describe your grades in school?
Mostly A's
Mostly B's
Mostly C's
Mostly D's
Have you ever smoked cigarettes?
Yes
No
Have you ever smoked electronic cigarettes (e-cigs, Juul, etc)?
Yes
No
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 or 10 years old
11 or 12 years old
13 or 14 years old
15 or 16 years old
17 years old or older
During the past 30 days, how many days did you have at least one drink of alcohol?
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
During your life, how many times have you used drugs (marijuana, synthetic marijuana, cocaine, heroin, inhalants, methamphetamines)?
0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 to 99 times
100 or more times
During the past 30 days, how many times did you use drugs (marijuana, synthetic marijuana, cocaine, heroin, inhalants, methamphetamines)?
0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 or more times
Have you ever been arrested?
Yes
No
What are your life aspirations/dreams?
Do you plan to go to college?
Yes
No
What clubs/sports/extracurricular activities are you involved in?
How often do you wear a seatbelt when riding in a car driven by someone else?
Never
Rarely
Sometimes
Most of the time
Always
During the past 30 days, on how many days did you text or e-mail while driving a car or other vehicle?
I did not drive a car or other vehicle during the past 30 days
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
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 or 3 days
4 or 5 days
6 or more days
During the past 12 months on how many days did you carry a weapon such as a gun, knife, or club (Do not count the days when you carried a gun only for hunting or for a sport, such as target shooting.)
0 days
1 day
2 or 3 days
4 or 5 days
6 or more days
During the past 12 months, how many times were you in a physical fight?
0 times
1 time
2 or 3 times
4 or 5 times
6 or 7 times
8 or 9 times
10 or 11 times
12 or more times
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
Have you ever had sexual intercourse?
Yes
No
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
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
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? (Count time spent playing games, watching videos, texting, or using social media on your smartphone, computer, Xbox, Playstation, iPad, or other tablet.)
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