2012 Healthy Youth Survey Form A

Transcription

1 2012 Healthy Youth Survey Form We are asking you to take part in this survey about issues facing students in communities in Washington. The questions in this survey ask for your opinions about yourself, your friends, your school, and your neighborhood or community. School, community, county, and state officials will use the information from this survey in planning future programs to help youth. Your answers to these questions are anonymous. This means that no one will know how you answered or which answer sheet is yours. Do not write your name anywhere on the answer sheet. Some of the questions are personal, such as asking about your relationships and whether you get in fights or use drugs. Some students may find some of the questions uncomfortable or upsetting. You will be given a list of numbers to call if you want to talk to someone about the survey or feelings it brings up. The survey is completely voluntary. You don t have to do this survey. You may skip any question you do not wish to answer or stop at any time. It will not affect your grades. Other students have said this survey is interesting and they enjoyed filling it out. We hope you will too. Please take a minute to read the instructions below before starting the survey. INSTRUCTIONS 1. This is not a test, so there are no right or wrong answers. 2. The questions should be answered by marking one of the answer spaces on the answer sheet. If you don t find an answer that fits exactly, use one that comes closest. If any question does not apply to you, or you are not sure of what it means, just leave it blank. 3. Your answers will be read by a computer. Please follow these instructions carefully. Use a pencil only. Make heavy mark inside the bubbles. Erase cleanly any answer you wish to change. Make no other markings or comments on the answer pages. 4. Some of the questions have the following format: Please mark in the bubble which of the four words best describes how you feel about that sentence. EXMPLE: Pepperoni pizza is one of my favorite foods. This kind of mark will work: Correct Mark D These kinds of marks will NOT work: Incorrect Marks In this example, the student marked yes because he or she thinks the statement is mostly true. D means definitely not true for you means mostly not true for you means mostly true for you means definitely true for you DSHS (5/11)

2 1. How old are you? a. 12 or younger b. 13 c. 14 d. 15 e. 16 f. 17 g. 18 h. 19 or older 2. What grade are you in? a. 7th b. 8th c. 9th d. 10th e. 11th f. 12th g. Ungraded or other 3. re you: a. Female b. Male 4. How do you describe yourself? (Select one or more responses.) a. merican Indian or laskan Native b. sian or sian merican c. lack or frican-merican d. Hispanic or Latino/Latina e. Native Hawaiian or other Pacific Islander f. White or Caucasian g. Other 5. What language is usually spoken at home? a. English b. Spanish c. Russian d. Ukrainian e. Vietnamese f. Chinese g. Korean h. Japanese i. Other 6. Who did you live with most of time in the last 30 days? a. Parent(s) and/or step-parents b. Relatives like a grandparent, an aunt, an older brother but NOT your parent(s) c. Foster care parent(s) d. The family of one of your friends e. Friends of yours with no adults present f. On your own g. Other 7. Where did you live most of the time in the last 30 days? a. In a house, apartment, or mobile home b. In a motel or hotel c. In a group home d. In a shelter e. In a car, park, or campground f. On the street g. Moved from place to place h. Other These statements and questions are about the neighborhood and community where you live. 8. How wrong would most adults in your neighborhood or community think it was for kids your age:. To use marijuana? c. little bit wrong. To drink alcohol? c. little bit wrong To smoke cigarettes? c. little bit wrong 9. How wrong do your parents feel it would be for you to:. Drink beer, wine, or hard liquor (for example: vodka, whiskey, or gin) regularly (at least once or twice a month)? c. little bit wrong. Smoke cigarettes? c. little bit wrong Smoke marijuana? c. little bit wrong 1

3 10. If a kid drank some beer, wine, or hard liquor (for example, vodka, whiskey, or gin) in your community would he or she be caught by the police? 11. If a kid smoked marijuana in your community would he or she be caught by the police? 12. If a kid carried a handgun in your community would he or she be caught by the police? 13. If you wanted to get some beer, wine, or hard liquor (for example, vodka, whiskey, or gin), how easy would it be for you to get some? a. Very hard b. Sort of hard c. Sort of easy d. Very easy 14. If you wanted to get some cigarettes, how easy would it be for you to get some? a. Very hard b. Sort of hard c. Sort of easy d. Very easy 15. If you wanted to get some marijuana, how easy would it be for you to get some? a. Very hard b. Sort of hard c. Sort of easy d. Very easy 16. If you wanted to get a drug like cocaine, LSD, or amphetamines, how easy would it be for you to get some? a. Very hard b. Sort of hard c. Sort of easy d. Very easy 17. If you wanted to get a handgun, how easy would it be for you to get one? a. Very hard b. Sort of hard c. Sort of easy d. Very easy 18. There are adults in my neighborhood or community I could talk to about something important. 19. Which of the following activities for people your age are available in your community?. Sports teams and recreation a. Yes b. No. Scouts, Camp Fire, 4-H Clubs, or other service clubs a. Yes b. No oys and Girls Club, YMC, or other activity clubs a. Yes b. No 20. During the average week, on how many days do you participate in supervised after-school activities either at school or away from school? Include activities such as sports, art, music, dance, drama, or community service, religious, or club activities. a. 0 days b. 1 2 days c. 3 or more days This section asks about your experiences with school. 21. How often do you feel the schoolwork you are assigned is meaningful and important? a. lmost always b. Often c. Sometimes d. Seldom e. Never 22. How interesting are most of your courses to you? a. Very interesting and stimulating b. Quite interesting c. Fairly interesting d. Slightly dull e. Very dull 23. How important do you think the things you are learning in school are going to be for you later in life? a. Very important b. Quite important c. Fairly important d. Slightly important e. Not at all important 2

4 24. Think back over the past year in school. How often did you:. Enjoy being in school? a. Never b. Seldom c. Sometimes d. Often e. lmost always. Hate being in school? a. Never b. Seldom c. Sometimes d. Often e. lmost always Try to do your best work in school? a. Never b. Seldom c. Sometimes d. Often e. lmost always 25. During the LST 4 WEEKS, how many whole days of school have you missed because you skipped or cut? b. 1 c. 2 d. 3 e. 4 5 f g. 11 or more 26. student is being bullied when another student, or group of students, say or do nasty or unpleasant things to him or her. It is also bullying when a student is teased repeatedly in a way he or she doesn t like. It is NOT bullying when two students of about the same strength argue or fight. In the last 30 days, how often have you been bullied? a. I have not been bullied b. Once c. 2 3 times d. bout once a week e. Several times a week 27. In my school, students have lots of chances to help decide things like class activities and rules. 28. There are lots of chances for students in my school to talk with a teacher one-on-one. 29. Teachers ask me to work on special classroom projects. 30. There are lots of chances for students in my school to get involved in sports, clubs, and other school activities outside of class. 31. I have lots of chances to be part of class discussions or activities. 32. My teacher(s) notices when I am doing a good job and lets me know about it. 33. The school lets my parents know when I have done something well. 34. I feel safe at my school. 35. My teachers praise me when I work hard in school. 3

5 36. Putting them all together, what were your grades like last year? a. Mostly s b. Mostly s c. Mostly Cs d. Mostly Ds e. Mostly Fs 37. re your school grades better than the grades of most students in your class? 38. How far did your mother get in school? a. Did not finish high school b. Graduated from high school or GED c. Had some college or technical training after high school d. Graduated from a 4-year college e. Earned an advanced graduate degree f. Don t know g. Does not apply 39. How far did your father get in school? a. Did not finish high school b. Graduated from high school or GED c. Had some college or technical training after high school d. Graduated from a 4-year college e. Earned an advanced graduate degree f. Don t know g. Does not apply The next questions ask about issues related to alcohol and other drugs. 40. During the past 30 days, have you seen or heard advertisements on TV, the Internet, the radio, or magazines about the dangers of kids drinking alcohol? a. Not in the past 30 days b. 1 3 times in the past 30 days c. 1 3 times per week d. Daily or almost daily e. More than once a day 41. NOT including talks on drinking and driving, in the past year have your parents or guardians talked to you about why you should not drink alcohol? a. Yes, a number of times b. Yes, once c. No d. I don t remember 42. During the past year in school, how many times did you get information in classes about reasons not to use alcohol or drugs? a. Never b. Once c. 2 3 times d. 4 or more times 43. How much do you think people risk harming themselves if they:. Smoke one or more packs of cigarettes per day? a. No risk b. Slight risk c. Moderate risk d. Great risk e. Not sure. Try marijuana once or twice? a. No risk b. Slight risk c. Moderate risk d. Great risk e. Not sure Smoke marijuana occasionally? a. No risk b. Slight risk c. Moderate risk d. Great risk e. Not sure Smoke marijuana regularly (at least once or twice a week)? a. No risk b. Slight risk c. Moderate risk d. Great risk e. Not sure E. Take one or two drinks of an alcoholic beverage (wine, beer, a shot, liquor) nearly every day? a. No risk b. Slight risk c. Moderate risk d. Great risk e. Not sure 44. What are the chances you would be seen as cool if you began drinking alcoholic beverages regularly, that is, at least once or twice a month? a. No or very little chance b. Little chance c. Some chance d. Pretty good chance e. Very good chance 4

6 45. If you had to guess, how many students in your grade at school drank alcohol during the past 30 days? a. 0 out of 10 (none) b. 1 out of 10 c. 2 out of 10 d. 3 out of 10 e. 4 out of 10 f. 5 out of 10 (about half) g. 6 out of 10 h. 7 out of 10 i. 8 out of 10 j. 9 out of 10 k. 10 out of 10 (all) 46. During the past 12 months, how many times were you in a physical fight? a. 0 times b. 1 time c. 2 3 times d. 4 5 times e. 6 or more times The next questions ask for your opinion. Remember, no one but you will know how you answered. 47. I think it is okay to take something without asking as long as you get away with it. 48. I think sometimes it is okay to cheat at school. 49. It is all right to beat up people if they start the fight. 50. It is important to be honest with your parents, even if they become upset or you get punished. The next questions ask about sad feelings and attempted suicide. Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life. 51. 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? a. Yes b. No 52. During the past 12 months, did you ever seriously consider attempting suicide? a. Yes b. No The next section asks about your experience with alcohol and other drugs. Remember, no one but you will know how you answered. 53. During the past 30 days, on how many days did you:. Smoke cigarettes? b. 1 2 days c. 3 5 days d. 6 9 days e days f. ll 30 days. Use chewing tobacco, snuff, or dip? b. 1 2 days c. 3 5 days d. 6 9 days e days f. ll 30 days Drink a glass, can, or bottle of alcohol (beer, wine, wine coolers, hard liquor)? b. 1 2 days c. 3 5 days d. 6 9 days e. 10 or more days Use marijuana or hashish (grass, hash, pot)? b. 1 2 days c. 3 5 days d. 6 9 days e. 10 or more days 5

7 E. Not counting alcohol, tobacco, or marijuana, use another illegal drug? b. 1 2 days c. 3 5 days d. 6 9 days e. 10 or more days F. Use derbisol (wagon wheels, hope)? b. 1 2 days c. 3 5 days d. 6 9 days e. 10 or more days G. Use a pain killer TO GET HIGH, like Vicodin, OxyContin (sometimes called Oxy or OC) or Percocet (sometimes called Percs)? b. 1 2 days c. 3 5 days d. 6 9 days e. 10 or more days 54. Some kids take a medicine prescribed by their doctor to help with hyperactivity or focus (DD). Some names for this medicine are Ritalin, dderall, or Concerta. In the past 30 days have you taken one of these drugs? a. No b. Yes, prescribed by my doctor for me c. Yes, but NOT prescribed by a doctor for me 55. If you have EVER used pain killers to get high, where did you usually get them? a. I did not use pain killers to get high b. I used my own prescription (from a doctor or dentist) c. family member gave them to me d. I took them from my home or someone else s home without permission e. I got them from a friend f. I got them from an acquaintance g. I got them from a drug dealer h. I got them from the internet i. I got them some other way 56. During the last year, have you felt that you needed help (such as counseling or treatment) for your alcohol, tobacco, or other drug use? a. I have not used alcohol or other drugs b. I have used alcohol and/or drugs, but I haven t needed help c. Yes, I felt I have needed help d. Not sure 57. Does your school provide a counselor, intervention specialist, or other school staff member for students to discuss problems with alcohol, tobacco, or other drugs? a. No b. Yes c. I m not sure 58. My school will punish students who are caught using alcohol or drugs. This section asks other questions about alcohol and tobacco. 59. Think back over the last 2 weeks. How many times have you had five or more drinks in a row? ( drink is a glass of wine, a bottle of beer, a shot glass of liquor, or a mixed drink.) b. Once c. Twice d. 3 5 times e. 6 9 times f. 10 or more times 60. How many times in the past year (12 months) have you been drunk or high at school? a. Never b. 1 2 times c. 3 5 times d. 6 9 times e. 10 or more times 61. During the past 30 days, how did you get alcohol (beer, wine, or hard liquor)? Choose all that apply. a. I did not get alcohol in the past 30 days b. I bought it from a store c. I got it from friends d. I got it at a party e. I got it from an older brother or sister f. I gave money to someone to get it for me g. I took it from home without my parents permission h. I got it at home with my parents permission i. I got it at a family celebration, ceremony, or party j. I got it some other way 6

8 62. If one of your best friends offered you a cigarette, would you smoke it? a. Definitely no b. Probably no c. Probably yes d. Definitely yes 63. Do you think that you will smoke a cigarette anytime in the next year? a. Definitely no b. Probably no c. Probably yes d. Definitely yes 64. How old were you the first time you:. Smoked marijuana? a. Never have b. 10 or younger c. 11 d. 12 e. 13 f. 14 g. 15 h. 16 i. 17 or older. Smoked a cigarette, even just a puff? a. Never have b. 10 or younger c. 11 d. 12 e. 13 f. 14 g. 15 h. 16 i. 17 or older Had more than a sip or two of beer, wine, or hard liquor (for example vodka, whiskey, or gin)? a. Never have b. 10 or younger c. 11 d. 12 e. 13 f. 14 g. 15 h. 16 i. 17 or older egan drinking alcoholic beverages regularly, that is, at least once or twice a month? a. Never have b. 10 or younger c. 11 d. 12 e. 13 f. 14 g. 15 h. 16 i. 17 or older 65. Have you ever, even once in your life:. Used inhalants a. No b. Yes. Used heroin? a. No b. Yes Used methamphetamines (meth, crystal meth, ice, crank)? Do not include other types of amphetamines. a. No b. Yes Used cocaine? a. No b. Yes E. Used steroids (muscle builders) without a doctor s prescription? a. No b. Yes The next questions ask about other behaviors. 66. How old were you when you first:. Got suspended from school? a. Never have b. 10 or younger c. 11 d. 12 e. 13 f. 14 g. 15 h. 16 i. 17 or older 7

9 . Got arrested? a. Never have b. 10 or younger c. 11 d. 12 e. 13 f. 14 g. 15 h. 16 i. 17 or older Carried a handgun? a. Never have b. 10 or younger c. 11 d. 12 e. 13 f. 14 g. 15 h. 16 i. 17 or older ttacked someone with the idea of seriously hurting them? a. Never have b. 10 or younger c. 11 d. 12 e. 13 f. 14 g. 15 h. 16 i. 17 or older 67. During the past 12 months, have you been a member of a gang? a. No b. Yes 68. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club on school property? a. 0 days b. 1 5 days c. 6 or more days The next questions ask for your opinions. 69. Think about the students in your school. If you had to guess, how wrong do most students in your grade think it is to drink alcohol regularly? c. little bit wrong 70. How wrong do YOU think it is for someone your age to:. Drink beer, wine, or hard liquor (for example vodka, whiskey, or gin) regularly? c. little bit wrong. Smoke cigarettes? c. little bit wrong Smoke marijuana? c. little bit wrong Use LSD, cocaine, amphetamines, or another illegal drug? c. little bit wrong 71. During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol? a. 0 times b. 1 time c. 2 3 times d. 4 5 times e. 6 or more times 72. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol? a. 0 times b. 1 time c. 2 3 times d. 4 5 times e. 6 or more times 73. In the past 12 months, how often have you gambled (bet) for money or possessions? a. Never in the past year b. Once or twice in the past year c. few times in the past year d. Once or twice a month e. t least once a week 74. Has YOUR gambling ever caused you problems at home, school or with your friends? a. I have not gambled b. Yes c. No 8

10 75. Think about your four best friends (the friends you feel closest to). In the past year (12 months), how many of your best friends have.... Participated in clubs, organizations or activities at school? of my friends. Made a commitment to stay drug-free? of my friends Liked school? of my friends Regularly attended religious services? of my friends E. Tried to do well in school? of my friends 76. Think of your four best friends (the friends you feel closest to). In the past year (12 months), how many of your best friends have.... Smoked cigarettes?. Tried beer, wine, or hard liquor (for example, vodka, whiskey, or gin) when their parents didn t know about it? Used marijuana? Used LSD, cocaine, amphetamines, or other illegal drugs? Sometimes we don t know what we will do as adults, but we may have an idea. Please try to guess how true these statements may be for you as an adult. 77. When I am an adult I will smoke cigarettes. 78. When I am an adult I will drink beer, wine, or liquor. 79. When I am an adult I will smoke marijuana. The next questions ask about what you would do in certain situations. 80. You re looking at CDs in a music store with a friend. You look up and see her slip a CD under her coat. She smiles and says, Which one do you want? Go ahead, take it while nobody s around. There is nobody in sight, no employees, and no other customers. What would you do now? a. Ignore her b. Grab a CD and leave the store c. Tell her to put the CD back d. ct like it s a joke and ask her to put the CD back 9

11 81. You are visiting another part of town and you don t know any of the people your age there. You are walking down the street and some teenager you don t know is walking toward you. He is about your size. s he is about to pass you, he deliberately bumps into you and you almost lose your balance. What would you say or do? a. Push the person back b. Say nothing and keep on walking c. Say, Watch where you re going, and keep on walking d. Swear at the person and walk away 82. You are at a party at someone s house and one of your friends offers you a drink containing alcohol. What would you say or do? a. Drink it b. Tell your friend, No thanks. I don t drink, and suggest that you and your friend go and do something else c. Just say, No, thanks, and walk away d. Make up a good excuse, tell your friend you had something else to do, and leave The next section asks about you and your friends. Remember, no one but you will know how you answered. Stolen or tried to steal a motor vehicle such as a car or motorcycle? of my friends E. een arrested? of my friends F. Dropped out of school? of my friends 84. How honest were you in filling out this survey? a. I was very honest b. I was honest pretty much of the time c. I was honest some of the time d. I was honest once in a while e. I was not honest at all 83. Think of your four best friends (the friends you feel closest to). In the past year (12 months), how many of your best friends have:. een suspended from school? of my friends. Carried a handgun? of my friends Sold illegal drugs? of my friends 10

12 11

13 The next set of questions asks about your family. When answering these questions, please think about the people you consider to be your family -parents, stepparents, grandparents, aunts, uncles, etc. 85. My parents ask if I ve gotten my homework done. 86. When I am not at home, one of my parents knows where I am and who I am with. 87. If I had a personal problem, I could ask my mom or dad for help. 88. The rules in my family are clear. 89. My family has clear rules about alcohol and drug use. 90. My parents give me lots of chances to do fun things with them. 91. My parents ask me what I think before most family decisions affecting me are made. 92. My parents notice when I am doing a good job and let me know about it. a. Never or almost never b. Sometimes c. Often d. ll the time. 93. How often do your parents tell you they re proud of you for something you ve done? a. Never or almost never b. Sometimes c. Often d. ll the time. 94. Do you enjoy spending time with your mother? 95. Do you enjoy spending time with your father? 96. If you drank some beer, wine, or liquor (for example vodka, whiskey, or gin) without your parent s permission, would you be caught by them? 97. Would your parents know if you did not come home on time? 98. If you carried a handgun without your parent s permission, would you be caught by them? 99. If you skipped school, would you be caught by your parents? 12

14 13

15 Tear here Tear here PGE 2 PGE C D E F G H C D E F G C D E F G C D E F G H I C D E F G C D E F G H C D C D C D C D C D C D C D C D C D C D C D C D C D C D C D *HYSForm!Page1* PGE 4 PGE 3 PGE C C D E C D E C D E C D E C D E C D E C D E F G C D E C D C D C D C D C D C D C D C D C D C D E C D C D E F G C D E F G 2012 Healthy Youth Survey Form PGE 4 PGE 5 PGE E E. F. C D E C D E C D E C D C D C D C D C D E C D C D C D E C D E C D E C D E C D E F G H I J K C D E F C D E F C D E C D E C D E C D E

16 2012 Healthy Youth Survey Form PGE G. C D E C PGE C PGE C D C D 55. C D E F G H I 69. C D 83.. C D E 56. C D 70.. C D. C D E 57. C. C D C D E 58. C D C D C D E 59. C D E F C D E. C D E 60. C D E 71. C D E F. C D E 61. C D E F G H I J 72. C D E 84. C D E 73. C D E PGE C D C D 74. C PGE C D C D 64.. C D E F G H I 75.. C D E 87. C D. C D E F G H I PGE 9. C D E 88. C D C D E F G H I C D E 89. C D C D E F G H I C D E 90. C D 65.. E. C D E 91. C D C D E 92. C D. C D E 93. C D C D E 94 C D E. C D E 95. C D 66.. C D E F G H I 77. C D 96. C D 78. C D 97. C D PGE 8. C D E F G H I C D E F G H I C D C D C D C D C D E F G H I *HYSForm!Page2*