Demographics Core How old are you? Demographics Core What is your sex? Demographics Core In what grade are you? Demographics Core Are you Hispanic or Latino? Demographics Core What is your race? (Select one or more responses.) Demographics Core During the past 12 months, how would you describe your grades in school? Demographics Acculturation How long have you lived in the United States? Demographics Acculturation How often do the people in your home speak a language other than English? Demographics Acculturation How often do people in your home speak the Ojibwe language? Demographics Acculturation Do you live in Wauwatosa? Traffic Safety Core When you ride a bicycle, how often do you wear a helmet? Traffic Safety Core When you rollerblade or ride a skateboard, how often do you wear a helmet? Traffic Safety Core How often do you wear a seat belt when riding in a car? Traffic Safety Core Have you ever ridden in a car driven by someone who had been drinking alcohol? Weapons Core Have you ever carried a weapon, such as a gun, knife, or club? Weapons Core Have you ever carried a weapon, such as a gun, knife, or club on school property? Threats and Personal Safety Core Have you ever been in a physical fight? Threats and Personal Safety Core Have you ever been bullied on school property? Threats and Personal Safety Core Have you ever not gone to school because you felt unsafe at school? Threats and Personal Safety Core Have you ever not gone to school because you felt unsafe on your way to or from school? Threats and Personal Safety Core Do you agree or disagree that bullying by other students is a problem at your school? Threats and Personal Safety Bullying During the past 12 months, have you been harassed, picked on, or bullied while riding on a school bus? Threats and Personal Safety Bullying During the past 12 months, how many times have you been harassed or bullied on school property? Threats and Personal Safety Bullying During the past 30 days, have you been the victim of a verbal slur because of your gender? Threats and Personal Safety Bullying During the past 30 days, have you been the victim of a verbal slur because of your weight, size, or physical appearance? Threats and Personal Safety Bullying Has anyone at your school ever touched you, said something to you, or displayed a picture or photograph that was sexual in nature and made you uncomfortable? Threats and Personal Safety Bullying Has someone ever stolen or deliberately damaged your property such as your cell phone, clothing, or books on school property? Threats and Personal Safety Bullying Have you ever been asked to send or post a sexually explicit photo of yourself? Threats and Personal Safety Bullying Have you ever sent or posted a sexually explicit photo of yourself? Threats and Personal Safety Bullying Have you ever been electronically bullied? (Include being bullied through e mail, chat rooms, instant messaging, Web sites, or texting.) Threats and Personal Safety Miscellaneous Have you ever done something to hurt yourself without wanting to die, such as cutting or burning yourself on purpose? Threats and Personal Safety School Experience Do you agree or disagree that harassment and bullying by other students is a problem at your school? Threats and Personal Safety School Experience Do you agree or disagree that violence is a problem at your school? Threats and Personal Safety School Experience How often do you feel safe and secure at school? Gang Activity Gang Activity During the past 12 months, have you been a member of a gang? Gang Activity Gang Activity Is there gang activity in your school? Depression and Suicide Core Have you ever felt so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities? Depression and Suicide Core Have you ever seriously thought about killing yourself? 1
Depression and Suicide Core Have you ever made a plan about how you would kill yourself? Depression and Suicide Core Have you ever tried to commit suicide? Tobacco Use Core Have you ever tried cigarette smoking, even one or two puffs? Tobacco Use Core How old were you when you smoked a whole cigarette for the first time? Tobacco Use Core During the past 30 days, on how many days did you smoke cigarettes? Tobacco Use Core During the past 30 days, how did you usually get your own cigarettes? (Select only one response.) Tobacco Use Core Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days? Tobacco Use Core 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? Tobacco Use Core During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars? Tobacco Use Core How wrong do your parents feel it would be for you to smoke cigarettes? Tobacco Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they smoke one or more packs of cigarettes per day? Tobacco Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they smoke one to five cigarettes per day? Tobacco Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they use smokeless tobacco regularly? Tobacco Use Peer Use How many of your friends would you estimate smoke cigarettes? Tobacco Use Peer Use How many of your friends would you estimate use smokeless tobacco? Tobacco Use Tobacco Use When you bought or tried to buy cigarettes in a store during the past 30 days, were you ever asked to show proof of age? Tobacco Use Tobacco Use During the past 30 days, onthe days yousmoked smoked, how many cigarettes did yousmoke per day? Tobacco Use Tobacco Use How old were you when you first: Smoked a cigarette, even a puff? Alcohol Use Core Have you ever had a drink of alcohol, other than a few sips? Alcohol Use Core How old were you when you had your first drink of alcohol other than a few sips? Alcohol Use Core During the past 30 days, did you have at least one drink of alcohol other than a few sips? Alcohol Use Core During the past 30 days, did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours? Alcohol Use Core How wrong do your parents feel it would be for you to drink alcohol? Alcohol Use Core Have you ever gotten drunk from drinking alcohol? Alcohol Use Alcohol Use How old were you when you first: Had more than one sip or two of beer, wine or hard liquor (for example, vodka, whiskey or gin)? Alcohol Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they have five or more drinks of an alcoholic beverage (beer, wine, liquor) once or twice each weekend? Alcohol Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they take one or two drinks of an alcoholic beverage (beer, wine, liquor) nearly every day? Alcohol Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they try one or two drinks of an alcoholic beverage (beer, wine, liquor)? Alcohol Use Parent Attitudes How would your parents or other adults in your family feel if you attended a party where alcoholic beverages were available? Alcohol Use Peer Use How many of your friends would you estimate drink alcoholic beverages (liquor, beer, wine)? Alcohol Use Peer Use How many of your friends would you estimate get drunk at least once a week? Marijuana Use Core Have you ever used marijuana? Marijuana Use Core During the past 30 days, did you use marijuana? Marijuana Use Core How wrong do your parents feel it would be for you to smoke marijuana? 2
Marijuana Use Family Interaction/Support How would your parents or other adults in your family feel if you smoked marijuana? Marijuana Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they smoke marijuana occasionally? Marijuana Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they try marijuana once or twice? Marijuana Use Marijuana Use How much do you approve or disapprove of people smoking marijuana occasionally? Marijuana Use Marijuana Use How old were you when you first: Smoked marijuana? Marijuana Use Peer Use How many of your friends would you estimate smoke marijuana or hashish? Other Drug Use Core Have you ever sniffed glue, or breathed the contents of spray cans, or inhaled any paints or sprays to get high? Other Drug Use Core During the past 12 months, has anyone offered, sold, or given you an illegal drug on school property? Other Drug Use Core Have you ever taken a prescription drug (such as OxyContin, Percocet, Vicodin, codeine, Adderall, Ritalin, or Xanax) without a doctor s prescription? Other Drug Use Core Have you ever taken a over the counter drug to get high? Other Drug Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they sniff glue, gases, or sprays once or twice? Other Drug Use Health Risk How much do you think people risk harming themselves (physically or in other ways), if they sniff glue, gases, or sprays regularly? Other Drug Use Other Drug Use Have you ever used a needle to inject any illegal drug into your body? Other Drug Use Other Drug Use Have you ever used steriod pills or shots without a doctor's prescription? Other Drug Use Other Drug Use How old were you when you sniffed glue, breathed the contents of aerosol spray cans, or inhaled any paints or sprays to get high for the first time? Other Drug Use Other Drug Use Have you ever used any form of cocaine, including powder, crack, or freebase? Other Drug Use Other Drug Use Have you ever used methamphetamines (also called speed, crystal, crank, or ice)? Other Drug Use Other Drug Use Have you ever used heroin (also called smack, junk, or China White)? Other Drug Use Other Drug Use Have you ever used ecstasy (also called MDMA)? Other Drug Use Other Drug Use Have you ever attended school under the influence of alcohol or other illegal drugs, such as marijuana or cocaine? Other Drug Use Other Drug Use Have you ever taken a over the counter drug to get high? Other Drug Use Other Drug Use Have you ever used any form of cocaine, including powder, crack, or freebase? Other Drug Use Peer Use How many of your friends would you estimate sniff glue, gases, or sprays? Other Drug Use Perception and Attitude Do you agree or disagree that it is important to you not to use alcohol or other drugs? Other Drug Use Perception and Attitude Do you agree or disagree that illegal drugs are a problem at your school? Other Drug Use Prescription During your life, have you ever taken a prescription drug, such as Ritalin, Adderall, or Xanax, without a doctor's prescription? Other Drug Use Prescription During your life, have you ever taken painkillers, such as OxyContin, Percocet, or Vicodin, without a doctor s prescription? Other Drug Use Prescription Have you ever taken a prescription drug (such as OxyContin, Percocet, Vicodin, codeine, Adderall, Ritalin, or Xanax) without a doctor s prescription? Sexual Behavior Core It is important to me to delay having sexual intercourse until...(select only one response.) Sexual Behavior Core Have you ever had sexual intercourse? Sexual Behavior Core How old were you when you had sexual intercourse for the first time? Sexual Behavior Core With how many people have you ever had sexual intercourse? Sexual Behavior Core The last time you had sexual intercourse, did you or your partner use a condom? 3
Sexual Behavior Family Interaction/Support Have your parents or other adults in your family ever talked with you about what they expect you to do or not to do when it comes to sex? Sexual Behavior Sexual Behavior Have you ever had oral sex? Sexual Behavior Sexual Behavior Have you ever had sexual intercourse? Weight Loss Core Have you ever increased your physical activity to lose weight or to keep from gaining weight? Weight Loss Core Have you ever chosen healthier foods (fruit, vegetables, whole grains) to lose weight or to keep from gaining weight? Weight Loss Weight Loss How do you describe your weight? Weight Loss Weight Loss Which of the following are you trying to do about your weight? Weight Loss Weight Loss Today did you eat breakfast? Weight Loss Weight Loss Have you ever increased your physical activity to lose weight or to keep from gaining weight? Weight Loss Weight Loss Have you ever chosen healthier foods (fruit, vegetables, whole grains) to lose weight or to keep from gaining weight? Weight Loss Weight Loss Have you ever vomited or taken laxatives to lose weight or to keep from gaining weight? Weight Loss Weight Loss Have you ever eaten less food, fewer calories, or food low in fat to lose weight or to keep from gainig weight? Weight Loss Weight Loss Have you ever taken 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)? Weight Loss Weight Loss Have you ever gone without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight? Eating Habits Core Today did you eat breakfast? Eating Habits Core Yesterday, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not include diet soda or diet pop)? Eating Habits Dietary Behaviors During the past 7 days, how many times did you eat fruit? (Do not count fruit juice.) Eating Habits Dietary Behaviors During the past 7 days, how many times did you eat vegetables? (Do not count vegetable juice.) Eating Habits Dietary Behaviors When you drink milk, what kind of milk do you usually drink? (Select only one response.) Eating Habits Dietary Behaviors Yesterday, how many times did you drink a power drink, such as Red Bull, Monster, or Volt? Eating Habits Family Interaction/Support About how often do you eat meals with one or more of the adults in your home? Eating Habits Family Interaction/Support Yesterday, did you eat a meal with your family? Eating Habits Food Security During the past 30 days, how often did you go hungry because there was not enough food in your home? Physical Activity Core Yesterday were you physically active for a total of at least 60 minutes? (Add up all the time you spend in any kind of physical activity that increases your heart rate and makes you breathe hard some of the time.) Physical Activity Core On an average school day, how many hours do you watch TV? Physical Activity Core 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? (Include activities such as Xbox, Play Station, Nintendo DS, ipod Touch, Facebook, and the Internet.) Physical Activity Core In an average week when you are in school, on how many days do you go to physical education (PE) classes? Physical Activity Core During the past 12 months, on how many sports teams did you play? (Include any teams run by your school or community groups.) Physical Activity Exercise In an average week when you are in school, on how many days do you walk or ride your bike to school when weather allows you to do so? Physical Activity Exercise 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? 4
Physical Activity Injured While Exercising During the past 30 days, did you see a doctor or nurse for an injury that happened while exercising or playing sports? Other Health Issues Core Has a doctor or nurse ever told you that you have asthma? Other Health Issues Core Do you still have asthma? Other Health Issues Core Have you ever been taught about AIDS or HIV infection in school? Other Health Issues Core Have you ever talked about AIDS or HIV infection with your parents or other adults in your family? Other Health Issues Diabetes Has a doctor or nurse ever told you that you have diabetes? Other Health Issues General Health Status How do you describe your health in general? Other Health Issues Health Check Up When was the last time you saw a dentist for a check up, exam, teeth cleaning, or other dental work? Other Health Issues Health Check Up When was the last time you saw a doctor or nurse for a check up or physical exam when you were not sick or injured? Other Health Issues Health Practices How often do you wash your hands before you eat? Other Health Issues Health Practices On an average school night, how many hours of sleep do you get? Other Health Issues HIV Prevention Education Have you ever talked about AIDS or HIV infection with your parents or other adults in your family? Other Health Issues HIV Prevention Education Have you ever been taught about AIDS or HIV infection in school? Social Support Core Do you agree or disagree that your family loves you and gives you help and support when you need it? Social Support Core Do you agree or disagree that your teachers really care about you and give you a lot of encouragement? Social Support Core Do you agree or disagree that you feel like you belong at this school. Social Support Core Is there at least one teacher or other adult in this school that you can talk to if you have a problem? Social Support Adult Interaction/Support Outside of school, is there an adult you can talk to about things that are important to you? Social Support Adult Interaction/Support Besides your parents, how many adults would you feel comfortable seeking help from if you had an important question affecting your life? Social Support Attitudes And Beliefs Do you agree or disagree that you feel alone in your life? Social Support Community Connectedness Do you agree or disagree that in your community you feel like you matter to people? Social Support Family Interaction/Support How often do your parents or other adults in your family talk with you about what you are doing? Social Support Family Interaction/Support Do you agree or disagree that your parents or other adults in your family have clear rules and standards for your behavior? Social Support Family Interaction/Support How often do your parents or other adults in your family ask where you are going or with whom you will be? Social Support Family Interaction/Support When you are away from home, how often do your parents or other adults in your family know where you are? Social Support Family Interaction/Support How often is there an adult at your home in the afternoon when you return from school? Social Support Family Interaction/Support On a school day, how many hours do you usually spend after school without an adult present? Social Support Family Interaction/Support Do you agree or disagree that your family loves you and gives you help and support when you need it? Social Support Family Interaction/Support During the past 12 months, how many times have you run away from home for more than 24 hours? Social Support School Experience Do you agree or disagree that you feel like you belong at this school? Social Support School Experience Do you agree or disagree that your school has clear rules and consequences for behavior? Social Support School Experience How often do you feel that you are accepted at school? Social Support School Support Is there at least one teacher or other adult in this school that you can talk to if you have a problem? Social Support School Support Do you agree or disagree that your teachers really care about you and give you a lot of encouragement? Miscellaneous Attitudes And Beliefs Do you agree or disagree that you are good at making decisions and following through on them? Miscellaneous Attitudes And Beliefs Do you agree or disagree that you can resist negative peer pressure and dangerous situations? Miscellaneous Attitudes And Beliefs Do you agree or disagree that you care about other people's feelings? Miscellaneous Attitudes And Beliefs Do you agree or disagree that you feel good about yourself? Miscellaneous Attitudes And Beliefs Do you agree or disagree that you stand up for your beliefs? 5
Miscellaneous Attitudes And Beliefs How often do you feel stress in your life? Miscellaneous Attitudes And Beliefs The next question refers to the Choking Game, also called Knock Out, Space Monkey, Flatlining, or The Fainting Game. This is an activity that some youth participate in to get a high by cutting off blood and oxygen to the brain with a belt, towel, rope, or other item. Which of the following is true for you?/ Miscellaneous Community Service Do you agree or disagree that it is important for you to help other people? Miscellaneous Community Service Do you participate in any extracurricular activities at school such as sports, band, drama, clubs, or student government? Miscellaneous Community Service During the past 12 months, how many times did you perform any organized community service as a non paid volunteer, such as serving meals to the elderly, picking up litter, helping out at a hospital, or building homes for the poor? Miscellaneous Community Service How important is it to you to help other people? Miscellaneous Drug Free Community How old were you when you first: Smoked a cigarette, even a puff? Miscellaneous Drug Free Community How much do you think people risk harming themselves (physically, or in other ways) if they: Smoke one ore more packs of cigarettes per day? Miscellaneous Drug Free Community How wrong do your parents feel it would be for you to: Smoke cigarettes? Miscellaneous Drug Free Community How old were you when you first: Had more than one sip or two of beer, wine or hard liquor (for example, vodka, whiskey or gin)? Miscellaneous Drug Free Community How much do you think people risk harming themselves (physically or in other ways) if they: Take one or two drinks of an alcoholic beverage (beer, wine, liquor) nearly every day? Miscellaneous Drug Free Community 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? Regular use of alcohol is defined as one or two drinks of an alcoholic beverage (beer, wine, liquor) nearly every day. Miscellaneous Drug Free Community How old were you when you first: Smoked marijuana? Miscellaneous Drug Free Community How much do you think people risk harming themselves (physically or in other ways) if they: Smoke marijuana regularly? Miscellaneous Drug Free Community How wrong do your parents feel it would be for you to: Smoke marijuana? Miscellaneous Drug Free Community On how many occasions (if any) have you had alcoholic beverages (beer, wine or hard liquor) to drink more than just a few sips during the past 30 days? Miscellaneous Drug Free Community How frequently have you smoked cigarettes during the past 30 days? Miscellaneous Drug Free Community On how many occasions (if any) have you used marijuana during the past 30 days? Miscellaneous Miscellaneous Do you participate in extra curricular activities? Please check all that apply: Miscellaneous Religion About how often do you usually attend religious services? Miscellaneous School Work Do you agree or disagree that at school you try hard to do your best work? Miscellaneous School Work How often do you come to classes without your homework finished? Miscellaneous School Work How often do you feel that schoolwork you are assigned is meaningful and important? Miscellaneous School Work How often do you try to do your best work in school? Miscellaneous School Work On an average school day, how many hours do you spend doing homework outside of school? Miscellaneous SPF SIG Do you believe that your parents support the minimum legal drinking age of 21 years old? Miscellaneous SPF SIG During the past 12 months, do you recall hearing, reading, or watching an advertisement about prevention of substance use? Miscellaneous SPF SIG During the past 12 months, have you driven a vehicle while you were under the influence of alcohol? Miscellaneous SPF SIG How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day? Miscellaneous SPF SIG How do you feel about someone your age smoking one or more packs of cigarettes a day? 6
Miscellaneous SPF SIG How do you feel about someone your age trying marijuana or hashish once or twice? Miscellaneous SPF SIG How do you feel about someone your age using marijuana once a month or more? Miscellaneous SPF SIG HOW MUCH do you think people RISK HARMING themselves physically or in other ways when they do the following: When they have five or more drinks of an ALCOHOLIC BEVERAGE once or twice a week? Miscellaneous SPF SIG HOW MUCH do you think people RISK HARMING themselves physically or in other ways when they do the following: When they smoke MARIJUANA once or twice a week? Miscellaneous SPF SIG 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 twice a month)? Miscellaneous SPF SIG How wrong do your parents feel it would be for you to: Have five or more drink of alcohol (beer, wine hard liquor) in a row, that is, within a couple of hours? Miscellaneous SPF SIG How wrong do your parents feel it would be for you to: Smoke cigarettes? Miscellaneous SPF SIG How wrong do your parents feel it would be for you to: Smoke marijuana? Miscellaneous SPF SIG Now think about the past 12 months through today. DURING THE PAST 12 MONTHS, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use? By PARENTS, we mean your biological parents, adoptive parents, step parents, or adult guardians whether or not they live with you. Miscellaneous SPF SIG Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Miscellaneous Sun Protection When you are outside for more than one hour on a sunny day, how often do you do one or more of the following: stay in the shade, wear long pants, wear a long sleeved shirt, or wear a hat that shades your face, ears, and neck? Miscellaneous Sun Protection When you are outside for more than one hour on a sunny day, how often do you wear sunscreen with an SPF of 15 or higher? Miscellaneous Television/Computer Use Do you have a TV in your room? Miscellaneous Television/Computer Use Do your parents have rules about what you watch on TV? Miscellaneous Television/Computer Use Do your parents have rules about what you do on the Internet? 7