Core Module. Middle School Questionnaire

Transcription

1 This survey asks about your behavior, experiences, and attitudes related to your school, health, and well being. It includes questions about use of alcohol, tobacco, and other drugs, and about bullying and violence. You do not have to answer these questions, but your answers will be very helpful in improving school and health programs. You will be able to answer whether or not you have done or experienced any of these things. Please do not write your name on this form or the answer sheet. Do not identify yourself in any other way. Please mark all of your answers on the answer sheet. Fill in the bubbles neatly with a #2 pencil. Do not write on the questionnaire. Mark only one answer unless told to Mark All That Apply. This survey asks about things you may have done during different periods of time, such as during your lifetime (you ever did something), or the past 12 months, or 30 days. Each provides different information. Please pay careful attention to these time periods. Thank you for taking this survey! Version M21 Fall 2017-Spring 2018 ~ 1 ~

2 Begin by writing your school s name at the top of the answer sheet. 1. Fill in the bubble for the letter M. 2. Fill in the bubble for the letter K. Next, we would like some background information about you. 3. What is your sex? A) Male B) Female 4. What grade are you in? A) 6th grade B) 7th grade C) 8th grade D) 9th grade E) 10th grade F) 11th grade G) 12th grade H) Other grade I) Ungraded 5. Are you of Hispanic or Latino origin? 6. What is your race? A) American Indian or Alaska Native B) Asian C) Black or African American D) Native Hawaiian or Pacific Islander E) White F) Mixed (two or more) races Version M21 Fall 2017-Spring 2018 ~ 2 ~

3 7. If you are Asian or Pacific Islander, which groups best describe you? (Mark All That Apply.) If you are not of Asian/Pacific Islander background, mark A) Does not apply. A) Does not apply; I am not Asian or Pacific Islander B) Asian Indian C) Cambodian D) Chinese E) Filipino F) Hmong G) Japanese H) Korean I) Laotian J) Vietnamese K) Native Hawaiian, Guamanian, Samoan, Tahitian, or other Pacific Islander L) Other Asian 8. What best describes where you live? A home includes a house, apartment, trailer, or mobile home. A) A home with one or more parent or guardian B) Other relative s home C) A home with more than one family D) Friend s home E) Foster home, group care, or waiting placement F) Hotel or motel G) Shelter, car, campground, or other transitional or temporary housing H) Other living arrangement 9. What is the highest level of education your parents or guardians completed? (Mark the educational level of the parent or guardian who went the furthest in school.) A) Did not finish high school B) Graduated from high school C) Attended college but did not complete four-year degree D) Graduated from college E) Don t know 10. Do you receive free or reduced-price lunches at school? (Receiving free or reduced-price lunches means that lunch at school is provided to you for free or you pay less for it.) C) Don t know 11. In the past three years, were you part of the Migrant Education Program or did your family move to find seasonal or temporary work in agriculture or fishing? C) Don t know Version M21 Fall 2017-Spring 2018 ~ 3 ~

4 12. What language is spoken most of the time in your home? A) English F) Tagalog B) Spanish G) Vietnamese C) Mandarin H) Korean D) Cantonese I) Other E) Taiwanese How well do you understand, speak, read, and write English? 13. Understand English 14. Speak English 15. Read English 16. Write English Very Well Well Not Well Not At All 17. How many days a week do you usually go to your school s after school program? A) 0 days E) 4 days B) 1 day F) 5 days C) 2 days D) 3 days 18. During the past 12 months, how would you describe the grades you mostly received in school? A) Mostly A s E) Mostly C s B) A s and B s F) C s and D s C) Mostly B s G) Mostly D s D) B s and C s H) Mostly F s 19. In the past 30 days, how often did you miss an entire day of school for any reason? A) I did not miss any days of school in C) 2 days the past 30 days D) 3 or more days B) 1 day Version M21 Fall 2017-Spring 2018 ~ 4 ~

5 20. In the past 30 days, did you miss a day of school for any of the following reasons? (Mark All That Apply.) A) Does not apply; I didn t miss any school B) Illness (feeling physically sick), including problems with breathing or your teeth C) Were being bullied or mistreated at school D) Felt very sad, hopeless, anxious, stressed, or angry E) Didn t get enough sleep F) Didn t feel safe at school or going to and from school G) Had to take care of or help a family member or friend H) Wanted to spend time with friends I) Use alcohol or drugs J) Were behind in schoolwork or weren t prepared for a test or class assignment K) Were bored or uninterested in school L) Had no transportation to school M) Other reason 21. During the past 12 months, about how many times did you skip school or cut classes? A) 0 times E) Twice a month B) 1 2 times F) Once a week C) A few times G) More than once a week D) Once a month How strongly do you agree or disagree with the following statements? Strongly Neither Nor Agree Agree Strongly Agree 22. I feel close to people at this school. 23. I am happy to be at this school. 24. I feel like I am part of this school. 25. The teachers at this school treat students fairly. 26. I feel safe in my school. 27. My school is usually clean and tidy. 28. Teachers at this school communicate with parents about what students are expected to learn in class. 29. Parents feel welcome to participate at this school. 30. School staff takes parent concerns seriously. 31. I try hard to make sure that I am good at my schoolwork. 32. I try hard at school because I am interested in my work. 33. I work hard to try to understand new things at school. 34. I am always trying to do better in my schoolwork. E E E E E E E E E E E E E Version M21 Fall 2017-Spring 2018 ~ 5 ~

6 Please mark on your answer sheet how TRUE you feel each of the following statements is about your SCHOOL and things you might do there. At my school, there is a teacher or some other adult 35. who really cares about me. 36. who tells me when I do a good job. 37. who notices when I m not there. 38. who always wants me to do my best. 39. who listens to me when I have something to say. 40. who believes that I will be a success. At school, 41. I do interesting activities. 42. I help decide things like class activities or rules. 43. I do things that make a difference. 44. I have a say in how things work. 45. I help decide school activities or rules. Not At All True A Little True Pretty Much True Very Much True Not At All True A Little True Pretty Much True Very Much True Version M21 Fall 2017-Spring 2018 ~ 6 ~

7 The next questions ask about the use of alcohol, tobacco, marijuana, and other drugs, including pills or medications, to get high or for reasons other than medical, as ordered or prescribed by a doctor. Keep the following definitions in mind: One drink of ALCOHOL, or alcoholic drink (beverage), means one regular size can/bottle of beer or wine cooler, one glass of wine, one mixed drink, or one shot glass of liquor. Questions about alcohol do not include drinking a few sips of wine for religious purposes. DRUG means any substance other than alcohol or tobacco, including pills and medications, used to get high ( loaded, stoned, or wasted ) or for purposes other than prescribed by a doctor. During your life, how many times have you used the following? 0 1 Time Number of or More 46. A cigarette, even one or two puffs 47. A whole cigarette 48. Smokeless tobacco (dip, chew, or snuff) 49. Electronic cigarettes, e-cigarettes, or other vaping device such as e-hookah, hookah pens, or vape pens 50. One full drink of alcohol (such as a can of beer, glass of wine, wine cooler, or shot of liquor) 51. Marijuana (smoke, vape, eat, or drink) 52. Inhalants (things you sniff, huff, or breathe to get high such as glue, paint, aerosol sprays, gasoline, poppers, gases) 53. Derbisol 54. Any other drug, pill, or medicine to get high or for reasons other than medical E F E F E F E F E F E F E F E F E F Version M21 Fall 2017-Spring 2018 ~ 7 ~

8 During your life, how many times have you been 0 1 Time Number of or More 55. very drunk or sick after drinking alcohol? 56. high (loaded, stoned, or wasted) from using drugs? 57. drunk on alcohol or high on drugs on school property? E F E F E F During your life, how many times have you used marijuana in any of the following ways: Number of 0 1 Time or More 58. Smoke it? 59. In an electronic or e-cigarette or other vaping device? 60. Eat or drink it in products made with marijuana? E F E F E F During the past 30 days, on how many days did you use 61. cigarettes? 62. smokeless tobacco (dip, chew, or snuff)? 63. electronic cigarettes, e-cigarettes, or other vaping device such as e-hookah, hookah pens, or vape pens? 64. one or more drinks of alcohol? 65. five or more drinks of alcohol in a row, that is, within a couple of hours? 66. marijuana (smoke, vape, eat, or drink)? 67. inhalants (things you sniff, huff, or breathe to get high )? 68. any other drug, pill, or medicine to get high or for reasons other than medical? 0 Days 1 Day 2 Days 3 9 Days Days Days E F E F E F E F E F E F E F E F Version M21 Fall 2017-Spring 2018 ~ 8 ~

9 During the past 30 days, on how many days on school property did you use 69. cigarettes? 70. smokeless tobacco (dip, chew, or snuff)? 71. electronic cigarettes, e-cigarettes, or other vaping device such as e-hookah, hookah pens, or vape pens? 72. at least one drink of alcohol? 73. marijuana (smoke, vape, eat, or drink)? 74. any other drug, pill, or medicine to get high or for reasons other than medical? 0 Days 1 Day 2 Days 3 9 Days Days Days E F E F E F E F E F E F How much do people risk harming themselves physically and in other ways when they do the following? How Much Risk or Harm Great Moderate Slight None 75. Smoke cigarettes occasionally 76. Smoke 1 or more packs of cigarettes each day 77. Use e-cigarettes (electronic) or vaping device occasionally compared to smoking cigarettes 78. Use e-cigarettes or vaping devices several times a day compared to smoking cigarettes 79. Drink alcohol (beer, wine, liquor ) occasionally 80. Have five or more drinks of alcohol once or twice a week 81. Use marijuana occasionally (smoke, eat, or drink) 82. Use marijuana daily Version M21 Fall 2017-Spring 2018 ~ 9 ~

10 How difficult is it for students in your grade to get any of the following if they really want them? 83. Cigarettes 84. E-cigarettes (electronic) or vaping device 85. Alcohol 86. Marijuana Very Difficult Fairly Difficult Fairly Easy Very Easy Don t Know E E E E 87. In your life, how many times have you ridden in a car driven by someone who had been using alcohol or drugs? A) Never B) 1 time C) 2 times D) 3 to 6 times E) 7 or more times Next are questions about violence, safety, harassment, & bullying on school property. 88. How safe do you feel when you are at school? A) Very safe B) Safe C) Neither safe nor unsafe D) Unsafe E) Very unsafe 89. In a normal week, how many days are you home after school for at least one hour without an adult there? A) Never B) 1 day C) 2 days D) 3 days E) 4 days F) 5 days Version M21 Fall 2017-Spring 2018 ~ 10 ~

11 During the past 12 months, how many times on school property have you Happened on School Property 0 1 Time 2 to 3 4 or More 90. been pushed, shoved, slapped, hit, or kicked by someone who wasn t just kidding around? 91. been afraid of being beaten up? 92. been in a physical fight? 93. had mean rumors or lies spread about you? 94. had sexual jokes, comments, or gestures made to you? 95. been made fun of because of your looks or the way you talk? 96. had your property stolen or deliberately damaged, such as your car, clothing, or books? 97. been offered, sold, or given an illegal drug? 98. damaged school property on purpose? 99. carried a gun? 100. carried any other weapon (such as a knife or club)? 101. been threatened or injured with a weapon (gun, knife, club, etc.)? 102. seen someone carrying a gun, knife, or other weapon? 103. been threatened with harm or injury? 104. been made fun of, insulted, or called names? Version M21 Fall 2017-Spring 2018 ~ 11 ~

12 During the past 12 months, how many times on school property were you harassed or bullied for any of the following reasons? [You were bullied if you were shoved, hit, threatened, called mean names, teased, or had other unpleasant physical or verbal things done to you repeatedly or in a severe way. It is not bullying when two students of about the same strength or power quarrel or fight.] 105. Your race, ethnicity, or national origin 106. Your religion 107. Your gender 108. Because you are gay or lesbian or someone thought you were 109. A physical or mental disability 110. You are an immigrant or someone thought you were 111. Any other reason 0 1 Time 2 to 3 4 or More 112. During the past 12 months, how many times did other students spread mean rumors or lies, or hurtful pictures, about you online, on social media, or on a cell phone? A) 0 times (never) B) 1 time C) 2 3 times D) 4 or more times 113. Do you consider yourself a member of a gang? 114. During the past 12 months, did you ever feel so sad or hopeless almost everyday for two weeks or more that you stopped doing some usual activities? 115. Did you eat breakfast today? 116. How many questions in this survey did you answer honestly? A) All of them B) Most of them C) Only some of them D) Hardly any Version M21 Fall 2017-Spring 2018 ~ 12 ~

13 117. Is your father, mother, or guardian currently in the military (Army, Navy, Marines, Air Force, National Guard, or Reserves)? C) Don t know 118. Which of the following best describes you? A) Straight (not gay) B) Gay or Lesbian C) Bisexual D) I am not sure yet E) Something else F) Decline to respond 119. Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?, I am not transgender, I am transgender C) I am not sure if I am transgender D) Decline to respond Version M21 Fall 2017-Spring 2018 ~ 13 ~

14 Ventura County Module This section asks a few more questions about school, tobacco, alcohol and other drugs, and other health issues. How strongly do you agree or disagree with the following statements? X1. Teachers and other adults at this school treat all students with respect. X2. Teachers and other adults encourage me to work hard in school so I can be successful in college or at the job I choose. X3 Teachers and other adults work hard to help me with schoolwork when I need it. X4. Teachers show how classroom lessons are important and helpful to me in real life. X5. This school promotes academic success for all students. X6. This school makes it clear how students are expected to act. X7. This school helps students solve conflicts with one another. X8. Students in this school respect each other s differences (for example, gender, race, culture, sexual orientation) Strongly Neither Nor Agree Agree Strongly Agree E E E E E E E E How true do you feel these statements are about you personally? Not at All True A Little True Pretty Much True Very Much True X9. I know where to go for help with a problem at school. X10. I have goals and plans for the future. X11. I plan to graduate from high school. X12. I plan to go to college or some other school/career program after high school. How strongly do you agree or disagree with the following statements? Strongly Strongly Agree Students at my school feel safe... Agree X13. in classrooms X14. during on-campus lunch X15. in the bathrooms X16. during passing periods X17. in the locker rooms X18. at after school activities

15 X19. During the past 12 months, on how many days did you have a lesson on alcohol, tobacco, and other drugs in school? ne; I had no lessons about alcohol, tobacco, or other drugs in school B) 1 3 days C) 4-6 days D) 7 or more X20. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days? X21. If you are currently using tobacco, how likely are you to try to quit? A) I don t currently use tobacco B) Definitely will C) Probably will D) May or may not E) Probably will not F) Definitely will not X22. In your opinion, how likely is it that a student would find help at your school to stop using cigarettes? t likely B) Somewhat likely C) Likely If you used tobacco during the past 12 months, did you do any of the following things at school to get help to quit using? I Did Not Use Tobacco No Yes X23. Go to a special group or class A B C X24. Talk to an adult at school about how to quit A B C X25. Talk to a peer helper about how to quit A B C X26. How much do people risk harming themselves physically and in other ways when they use e-cigarettes or other vaping devices occasionally? X27. How much do people risk harming themselves physically and in other ways when they use e-cigarettes or other vaping devices every day? How much risk or harm Great Moderate Slight None School-Related Activities: In middle school/junior high or high school, how often did you participate in the following activities? I have never participated in this Once or twice Three times or more X28. Touring the Bus of Tobacco Horrors A B C X29. Attending anti-tobacco assemblies or presentations A B C

16 X30. Attending the Teens Kick Ash Youth Tobacco-Free Advocacy Conference X31. Creating an anti-tobacco art or media project (for example, poster contest, radio announcement, video public service announcement, journalism article) X32. School-related clubs or extracurricular activities, other than sports (for example, Friday Night Live, ASB, Drama Club, Chess Club, Spanish Club, GSA) I have never participated in this Once or twice Three times or more A B C A B C A B C X33. Sports (in or out of school) A B C X34. Music, dance, or art (in or out of school) A B C X35. In the past 12 months, did you want to talk to an adult professional (such as a doctor, counselor or therapist) about feeling sad, stressed, or depressed? C) I don t know X36. If I felt sad, stressed, or depressed, I would (Mark all that apply) A) Talk to a teacher or another adult at school B) Talk to my parents or someone else in my family C) Get help from a counselor, doctor or therapist D) Talk to my friends E) Not know what to do X37. If you were sad, stressed, or depressed, would any of these things stop you from talking to an adult professional? (Mark all that apply) A) I don t know where to go for help B) There isn t anyone I can talk to C) They wouldn t understand D) People would think there s something wrong with me E) My parents might find out F) Other students might find out G) I don t have a way to pay for it H) Other X38. When did you last visit a dentist to get your teeth checked, cleaned, or have work done on them? A) I ve never been to a dentist to have my teeth checked B) Within the last year C) More than 1 year ago D) More than two years ago E) I don t know/remember

17 School Climate Module SUPPLEMENT 2 How strongly do you agree or disagree with the following statements about your school? Strongly Neither Nor Agree Agree Strongly Agree Y1. Students at this school are motivated to learn. Y2. Adults at this school encourage me to work hard so I can be successful in college or at the job I choose. Y3. My teachers work hard to help me with my schoolwork when I need it. Y4. Teachers show how classroom lessons are helpful to students in real life. Y5. Teachers give students a chance to take part in classroom discussions or activities. Y6. This school is a supportive and inviting place for students to learn. Y7. Teachers go out of their way to help students. Y8. Teachers help students catch up when they return from an absence. Y9. My teachers give me useful feedback on my work. Y10. Adults at this school treat all students with respect. Y11. Students treat teachers with respect. Y12. The school rules are fair. Y13. All students are treated fairly when they break school rules. Y14. This school clearly informs students what would happen if they break school rules. Y15. The rules in this school are too strict. Y16. It is easy for students to get kicked out of class or get suspended. Y17. Students get in trouble for breaking small rules. E E E E E E E E E E E E E E E E E Version MSHS21 Fall 2017 Spring 2018 ~ 1 ~ Middle & High School Questionnaire School Climate Module

18 School Climate Module Y18. Teachers are very strict here. Y19. Rules in this school are made clear to students. SUPPLEMENT 2 Y20. This school makes it clear how students are expected to act. Y21. Students enjoy doing things with each other during school activities. Y22. Students care about each other. Y23. Students treat each other with respect. Y24. Students get along well with each other. Y25. This school encourages students to feel responsible for how they act. Y26. Students are often given rewards for being good. Y27. This school encourages students to understand how others think and feel. Y28. Students are taught that they can control their own behavior. Y29. This school helps students resolve conflicts with one another. Y30. This school encourages students to care about how others feel. Y31. Teachers here make it clear to students that bullying is not tolerated. Y32. If another student was bullying me, I would tell one of the teachers or staff at school. Y33. Students tell teachers when other students are being bullied. Y34. If I tell a teacher that someone is bullying me, the teacher will do something to help. Y35. Students here try to stop bullying when they see it happening. Strongly Neither Nor Agree Agree Strongly Agree E E E E E E E E E E E E E E E E E E Version MSHS21 Fall 2017 Spring 2018 ~ 2 ~ Middle & High School Questionnaire School Climate Module

19 School Climate Module SUPPLEMENT 2 Y36. I have been disrespected by an adult at this school because of my race, ethnicity, or culture. Y37. There is a lot of tension in this school between people of different cultures, races, or ethnicities. Y38. Students in this school respect each other s differences (for example, gender, race, culture, sexual orientation). Y39. Adults in this school respect differences in students (for example, gender, race, culture, sexual orientation). Y40. Teachers show that they think it is important for students of different races and cultures at this school to get along with each other. Strongly Neither Nor Agree Agree Strongly Agree E E E E E Y41. The schoolyard and buildings are clean and in good condition. Y42. My classroom is so crowded it is hard to concentrate and learn. Y43. I eat my lunch at the right time of day. Y44. I have plenty of time to eat my lunch. Y45. The school grounds are kept clean. Y46. Students pay attention in class. Y47. Students try their best in school. Y48. Students usually follow the rules at school. Y49. Students turn in their homework on time. Y50. This school promotes academic success for all students. Y51. When there is a conflict between people, this school tries to make sure all sides are heard to help resolve the conflict (like restorative practices). Y52. This school has clean and drinkable water. Y53. This school has helped me put my college and career goals and experiences in a plan which I update every year. Y54. This school has helped me learn about colleges, how to apply to them, and get financial aid if I need it. Y55. This school has helped me think about and explore future career options. E E E E E E E E E E E E E E E Version MSHS21 Fall 2017 Spring 2018 ~ 3 ~ Middle & High School Questionnaire School Climate Module

20 Alcohol & Other Drugs Module SUPPLEMENT 3 About how old were you the first time you tried any of these things? Never Years of Age 10 or Under or Over Z1. A drink of an alcoholic beverage (other than a sip or two) Z2. Part or all of a cigarette Z3. An electronic cigarette (e-cigarette or vaping device) Z4. Marijuana (smoke, eat, or drink) Z5. Any other illegal drug or pill to get high E F G H I J E F G H I J E F G H I J E F G H I J E F G H I J Z6. If you drink alcohol, how much do you usually drink? A) I don t drink alcohol B) Just enough to feel it a little C) Enough to feel it moderately D) Until I feel it a lot or get really drunk Z7. Have you used alcoholic beverages, marijuana, or other drugs in the past 12 months for any of the following reasons? (Mark All That Apply.) A) Does not apply, I haven t used alcohol, marijuana, or other drugs in the past 12 months. B) To experiment (try using) C) To get high D) To have a good time with friends E) To fit in with a group you like F) Because of boredom G) To relax H) To get away from problems I) Because of anger or frustration J) To get through the day K) Because it made you feel better L) To seek deeper insights and understanding M) None of the above Z8. In the past 12 months, have you been suspended from school one or more times? Z9. How do most students at your school who drink alcohol usually get it? (Mark All That Apply.) A) At school B) At parties C) At concerts or other social events D) At their own home E) From adults at friends homes F) From friends or another teenager G) Get adults to buy it for them Version M21 Fall 2017 Spring 2018 ~ 1 ~ H) Buy it themselves from a store (convenience store, liquor store, grocery, mini mart) I) At bars, clubs, or gambling casinos J) Other K) Don t know Alcohol & Other Drugs Module

21 Alcohol & Other Drugs Module SUPPLEMENT 3 Z10. How do most kids at your school who use marijuana usually get it? (Mark All That Apply.) A) At school F) From friends or another teenager B) At parties G) Buy it at a marijuana dispensary C) At concerts or other social events H) At bars or clubs D) At their own home I) Other E) From an adult acquaintance J) Don t know How do you feel about someone your age doing the following? Z11. Having one or two drinks of any alcoholic beverage nearly every day Z12. Trying marijuana once or twice Z13. Using marijuana once a month or more regularly Neither Approve Nor Disapprove Somewhat Disapprove Strongly Disapprove A B C A B C A B C Z14. During the past 12 months, have you talked with at least one of your parents or guardians about the dangers of alcohol or drug use? Z15. During the past 12 months, have you heard, read, or watched any messages about not using alcohol or drugs? How wrong do your parents or guardians feel it would be for you to do the following? Z16. Take one or two drinks of alcohol nearly every day Z17. Smoke tobacco Z18. Use marijuana (smoke, eat, or drink) Z19. Use prescription drugs to get high or for reasons other than prescribed Very Wrong How wrong would your close friends feel it would be if you did the following? Z20. Take one or two drinks of alcohol nearly every day Z21. Smoke tobacco Z22. Use marijuana (smoke, eat, or drink) Z23. Use prescription drugs to get high or for reasons other than prescribed Wrong A Little Wrong Not at All Wrong Very Wrong Wrong A Little Wrong Not at All Wrong Version M21 Fall 2017 Spring 2018 ~ 2 ~ Alcohol & Other Drugs Module

22 Alcohol & Other Drugs Module SUPPLEMENT 3 Z24. Have you ever used an e-cigarette or vaping device to consume any of the following? (Mark All That Apply.) A) I ve never used an e-cigarette or vaping device. B) Nicotine or tobacco substitute C) Marijuana or THC D) Amphetamines, cocaine, or heroin E) Alcohol F) A flavored product without nicotine, alcohol, or other drug G) Any other product or substance Version M21 Fall 2017 Spring 2018 ~ 3 ~ Alcohol & Other Drugs Module

23 District After School Module SUPPLEMENT 3 The next questions are about what you do after school is over, before dinner time (about 3:00 to 6:00 in the afternoon). Z1. How safe do you feel in the neighborhood where you live? A) Very safe B) Safe C) Neither safe nor unsafe D) Unsafe E) Very unsafe Z2. Where do you usually go right after school is over? (Mark Only ONE Answer.) A) Your home, or another home (such as a friend, relative, or neighbor), with an adult there B) Your home, or another home, without an adult there C) A park or recreation program D) A community, volunteer, or church group E) Stay at school for an after school program F) Stay at school for an extra class, tutoring, or activity such as band, sports, or a club G) To a job H) Some other place Z3. What do you usually do after school is over? (Mark ALL That You Do For About One Hour Or More.) A) Do your schoolwork (homework or studying) B) Get help with your schoolwork from an adult (such as a tutor) C) Take private classes or lessons such as art, music, or dance D) Play or practice a sport E) Hang out with friends (talking, playing games, going to the mall or a movie) F) Watch TV or play video games G) Do religious activities or get religious instruction H) Work at a job I) Other Version M21 Fall 2017 Spring 2018 ~ 1 ~ District After School Module

24 District After School Module SUPPLEMENT 3 We d like to know if your school has an after school program and what you may have heard about it. Z4. Please mark whether you agree with each of the following statements. (Mark ALL That Are True For You.) A) My school doesn t have an after school program. B) I don t know if my school has an after school program. C) I wish my school had an after school program. D) I don t know much about the after school program. E) It has activities that we usually don t have during the school day. F) The after school program doesn t interest me. G) It is a safe place to be after school. H) It helps you with schoolwork. I) The students that attend it really like it. J) I do not attend, but I would like to. Z5. In a normal school week, how many days do you usually go to your school s after school program in the afternoon? A) Does not apply, my school doesn t have an after school program B) 0 days C) 0 days, but I would like to go to an after school program D) 1 day E) 2 days F) 3 days G) 4 days H) 5 days Version M21 Fall 2017 Spring 2018 ~ 2 ~ District After School Module

25 Tobacco Module SUPPLEMENT 3 This section contains questions about tobacco use, attitudes, and your experiences with tobacco education at school. Z1. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days? Z2. Did you ever smoke to control your weight? Z3. 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 Z4. Have you smoked 100 cigarettes in your life? 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 Z5. If you smoked cigarettes during the past 30 days, how did you usually get them? (Select Only One Response.) A) I did not smoke cigarettes in the past 30 days. B) I bought them in a store such as a convenience store, supermarket, 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) I took them from a store or family member. G) A friend gave them to me. H) A person 18 years or older gave them to me. I) Other people gave them to me. J) I got them some other way. Z6. During the past 30 days, on how many days did you smoke any cigars, cigarillos, or little cigars (Swishers, Black&Mild, or Prime )? A) 0 days B) 1 to 2 days C) 3 to 5 days D) 6 to 9 days E) 10 to 19 days F) 20 to 30 days Version MSHS21 Fall 2017 Spring 2018 ~ 1 ~ Middle & High School Questionnaire Tobacco Module

26 Tobacco Module SUPPLEMENT 3 Z7. If you now smoke cigarettes, would you like to quit smoking? A) I don t smoke cigarettes; does not apply B) No C) Yes Z8. If you are currently using tobacco, how likely are you to try to quit? A) I don t use tobacco; does not apply B) Definitely will C) Probably will D) May or may not E) Probably will not F) Definitely will not Z9. How many times have you tried to quit smoking cigarettes? A) I don t smoke cigarettes; does not apply B) 0 times C) 1 time D) 2 to 3 times E) 4 or more times Z10. How much control do you have over whether you quit using tobacco? A) I don t use tobacco; does not apply B) No control at all C) A little control D) Medium control E) A lot of control F) Total control If you used tobacco during the past 12 months, did you do any of the following things at school to get help to quit using? Z11. Go to a special group or class Z12. Talk to an adult at your school about how to quit Z13. Talk to a peer helper about how to quit I Did Not Use Tobacco No Yes A B C A B C A B C Z14. How hard would it be for you to refuse or say no to a friend who offered you a cigarette to smoke? A) Very hard B) Hard C) Easy D) Very easy Version MSHS21 Fall 2017 Spring 2018 ~ 2 ~ Middle & High School Questionnaire Tobacco Module

27 Tobacco Module SUPPLEMENT 3 During the past 12 months, did you do any of these things at school? Z15. Have lessons about tobacco and its effects on the body Z16. Practice different ways to refuse or say no to tobacco offers No Yes Not Sure A B C A B C Z17. How likely do you think it is that you will smoke one or more cigarettes in the next year? A) I am sure it will not happen B) It probably will not happen C) There is an even chance (50 50) that it will happen D) It probably will happen E) It will happen for sure Z18. About how many adults you know smoke cigarettes? ne of them B) Some C) Many D) Most or all Please indicate whether or not you agree with the following statements: Z19. Smoking makes kids look grown up. Z20. Smoking makes your teeth yellow. Z21. Smoking is cool. Z22. Smoking makes you smell bad. Z23. Smoking helps you make friends. Z24. Smoking is bad for your health. Z25. Smoking helps you relax. Z26. Smoking helps control your weight. Very Much Agree Agree Very Much Z27. How do you feel about someone your age smoking one or more packs of cigarettes a day? A) Neither approve nor disapprove B) Somewhat disapprove C) Strongly disapprove Z28. How do you think your close friends would feel about you smoking one or more packs of cigarettes a day? A) Neither approve nor disapprove B) Somewhat disapprove C) Strongly disapprove Version MSHS21 Fall 2017 Spring 2018 ~ 3 ~ Middle & High School Questionnaire Tobacco Module

28 Tobacco Module SUPPLEMENT 3 Z29. During the past 12 months, have you talked with at least one of your parents or guardians about the dangers of tobacco use? Z30. During the past 12 months, how many times did you see someone smoking tobacco in a movie you watched? A) 0 times B) 1 time C) 2 times D) 3 times E) 4-6 times F) 7 or more times Z31. Think about a group of 100 students (about three classrooms) in your grade. About how many students do you think smoke cigarettes at least once a month? A) 0 B) 10 C) 20 D) 30 E) 40 F) 50 G) 60 H) 70 I) 80 J) 90 K) 100 Version MSHS21 Fall 2017 Spring 2018 ~ 4 ~ Middle & High School Questionnaire Tobacco Module