(Note that the questions probe nearly every facet of a student's personal life and many assume that the child has experienced the behaviors described. - Ed.)
Physical Behaviors Module
- During the past 30 days, did you: Vomit or take laxatives to lose weight or to keep from gaining weight?
- How many times during the past 7 days did you eat a meal with your family?
Alcohol, Tobacco & Drugs Module
- During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
- How many times did you use chewing tobacco or snuff in: the last 24 hours? the last 7 days?
- How many drinks of alcohol have you had in: the last 24 hours? the last 7 days?
- How many times did you use marijuana or hashish in: the last 24 hours? the last 7 days?
- During your life, how many times have you used any form of cocaine, including powder, crack or freebase?
- During your life, how many times have you used heroin (also called smack, junk, or China White)?
- During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice?)
- During your life, how many times have you used a needle to inject any illegal drug into your body?
- Sometimes we don't know what we will do as adults, but we may have an idea. Please tell us how true these statements may be for you as an adult: (Choices are "NO! no, yes, YES!")
When I am an adult, I will smoke cigarettes.
When I am an adult, I will drink beer, wine or liquor.
When I am an adult, I will smoke marijuana.
Questions about AIDS/HIV*
- How old were you when you had sexual intercourse for the first time?
- During your life, with how many people have you had sexual intercourse?
- During the past 3 months, with how many people did you have sexual intercourse?
- Did you drink alcohol or use drugs before you had sexual intercourse the last time?
- The last time you had sexual intercourse, did you or your partner use a condom?
- The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy?
- How many times have you been pregnant or gotten someone pregnant?
- If you wanted them, where would you go to get condoms?
* All but questions 27-28 (not included here due to space limitations) in the AIDS/HIV section may be omitted for 6th grade only.
Questions about Health Care
- Have you used the School Based Health Center services at your school?
Questions about Parent Supervision
- Over the last 2 days, about how much time (total) have you spent without any adults around?
- Please mark how you feel about your family relationships: People in my family often insult or yell at each other. People in my family have serious arguments. We argue about the same things in my family over and over.
Questions About Family Substance Use
- Has anyone in your family ever had a severe alcohol or drug problem?
- How many times have you changed homes since kindergarten?
Questions About Intentions
- Do you think you will try a cigarette soon?
- At any time during the next year, do you think you will smoke a cigarette?
- Does someone living in your house (other than you) smoke cigarettes?
- How long can you go without smoking before you feel like you need a cigarette?
Personal Safety, Harassment, and Violence-Related Behavior Module
- During the past 12 months, did you ever seriously consider attempting suicide?
- During the past 12 months, how many times did you actually attempt suicide?
- During the past 12 months, did your boyfriend or girlfriend ever hit, slap or physically hurt you on purpose?
- How many times in the past 3 months have you set a fire where it didn't belong, without adult permission or supervision?
- During the past 30 days, on how many days did you: Carry a gun? Carry a weapon other than a gun? Carry a gun on school property? Carry a weapon other than a gun (such as a knife, club, or other weapon not allowed at school) on school property?
- If you carried a handgun in the past 30 days, who did the handgun belong to?
- If you wanted to get a handgun, how easy would it be for you to get one?