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( 172. …treat students with respect. 2021 FAIRFAX COUNTY )
( Youth Survey of 8th, 10th, and 12th Grade Students )
( Strongly Agree )
( Agree Thank you for agreeing to participate in this study. These questions ask your opinion about a )
( Disagree )
( Strongly Disagree number of things concerning you, your friends, your family, your neighborhood, and your )
( community. )
( )
( 173. How honest were you in filling out this )
( survey? DO NOT write your name on this survey. Your individual answers to the survey are anonymous, )
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( I was very honest which means that no one will know how you answered. Student answers will be summarized in a )
( I was honest pretty much of the time report that will not include anyone’s name. This survey is completely voluntary. You can skip any )
( I was honest some of the time )
( I was honest once in a while questions that you do not want to answer. )
( I was not honest at all )
( Be sure to read the instructions below before you begin. Thank you very much. )
( )
( This is the end of the survey. )
( Thank you for participating. )
( INSTRUCTIONS )
( )
( 1. This is not a test, so there are no right or wrong answers. )
( )
( )
( 2. All of the questions should be answered by marking one of the answer spaces unless otherwise )
( noted. If you do not find an answer that fits exactly, use the one that comes closest. If any )
( )
( question does not apply to you, or you are not sure what it means, just leave it blank. )
( )
( 3. For questions that have the following answers: NO!! no yes YES!! )
( )
( )
( Mark the big YES!! if you think the statement is DEFINITELY TRUE for you. )
( Mark the little yes if you think the statement is MOSTLY TRUE for you. )
( )
( Mark the little no if you think the statement is MOSTLY NOT TRUE for you. )
( Mark the big NO!! if you think the statement is DEFINITELY NOT TRUE for you. )
( )
( Example: Chocolate is the best ice cream flavor. )
( )
( @@@
NO!! @@@
no @@@!@@
yes YES!! )
( )
( 4. Your answers will be read automatically by a scanner and computer. Please follow these )
( )
( instructions carefully. )
( )
( MARKING INSTRUCTIONS )
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( )
( a. Use a No. 2 pencil or a blue or black pen only.
This kind of mark will work: )
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( Correct Mark )
( b. Do not use pens with ink that soaks through the paper. )
( @ @!@ @ )
( c. Make solid marks that fill the response completely. These kinds of marks will NOT work: )
( Incorrect Marks )
( d. Make no stray marks on this form.
v@ y@w @ x@ )
( )
( )
( )
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( PLEASE DO NOT WRITE IN THIS AREA PLEASE DO NOT WRITE IN THIS AREA
)
16 1
( ] ]] ] ]] ] ] ] ]] ] )
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( )
( These questions ask for some )
( general information about the people 9. What language do you use most often at 161. …have you sexually harassed another student? 166. My school takes complaints of sexual )
( completing the survey. home? Never 10 to 19 times discrimination and sexual harassment )
( Amharic Korean 1 to 2 times 20 to 29 times seriously and responds effectively to the )
( Arabic Spanish 3 to 5 times 30 to 39 times
complaints it receives. )
( Please mark the response that best Chinese Urdu 6 to 9 times 40 or more times Strongly Agree )
( describes you. English Vietnamese Agree )
( Farsi Other Neutral )
( 1. How old are you? 162. …were you aware of sexual rumors being Disagree )
( 10 13 16 19 or older
10. Has your parent or guardian ever served in spread at school or at a school-sponsored Strongly Disagree )
( 11 14 17
the military (Army, Navy, Air Force, Marines, activity, either verbally or through electronic )
( 12 15 18
Coast Guard, Space Force, National Guard, means such as texting or social media? )
( and Reserves)? Never 10 to 19 times 167. During the past year, I have witnessed an act )
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( 2. What grade are you in? Yes No Not Sure 1 to 2 times 20 to 29 times of sexual discrimination or sexual )
( harassment against a student by a student, )
( 8th 10th 12th 11. Do you have someone in your family (like a 3 to 5 times 30 to 39 times
faculty member, or a third party. )
( parent, brother, sister) who is currently in the 6 to 9 times 40 or more times
)
( 3. Are you: military (Army, Navy, Air Force, Marines, Yes No
)
( Female Male Coast Guard, Space Force, National Guard, 163. If I observed or was a victim of sexual )
( and Reserves)? discrimination, including sexual harassment 168. During the past year, I reported an act of )
( 4. Some people describe themselves as Yes No Not Sure or sexual violence, I would know who to sexual discrimination or sexual harassment )
( transgender when their sex at birth does not
report that information to. to school personnel. )
( match the way they think or feel about their
Yes No
)
( gender. Are you transgender? The next section asks about your experiences at Strongly Agree )
( No, I am not transgender school. Agree )
( Yes, I am transgender Neutral )
( I am not sure if I am transgender Disagree
The next section asks about your perceptions of respect )
( I do not know what this question is asking
12. Putting them all together, what were your Strongly Disagree )
grades like last year? at your school.
( )
( 5. Which of the following best describes you?
Mostly Fs Mostly Bs )
( Mostly Ds Mostly As 164. I would feel comfortable reporting sexual How strongly do you agree or disagree with the )
Heterosexual (straight) discrimination or sexual harassment or
( Mostly Cs following statements about this school? Most )
Gay or lesbian assault to school faculty or staff.
( 13. During the last four weeks, how many days teachers and other adults at this school… )
Bisexual
( of school have you missed because you Strongly Agree )
Not sure
( skipped or "cut"? Agree 169. …care about students. )
( 6. What do you consider yourself to be? Neutral Strongly Agree
)
( Select ONE only.
None 4-5 days
Disagree Agree
)
( 1 day 6-10 days
Strongly Disagree Disagree
)
Hispanic or Latino
( 2 days 11 or more days
Strongly Disagree
)
( Not Hispanic nor Latino 3 days )
( 14. I think sometimes it is okay to cheat at school. 165. If you would not feel comfortable reporting )
( 7. What do you consider yourself to be? )
Select ONE OR MORE. an act of sexual discrimination or sexual 170. …want students to do well.
( NO!! no yes YES!! harassment to school faculty or staff, please )
( American Indian or Alaskan native
How much do you agree or disagree with the indicate why: (Choose ALL that apply) Strongly Agree )
( Asian
following? I would be more comfortable handling the
Agree )
( Black or African-American
situation myself
Disagree )
( Native Hawaiian or other Pacific Islander
15. I can do well in school if I want to.
Strongly Disagree )
I do not know a trusted adult to tell
( )
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White
( Strongly Agree Disagree I would be afraid of retaliation or continued )
8. Think of where you live most of the time. harassment 171. …listen to what students have to say.
( Which of the following people live there
Agree Strongly Disagree )
( with you?Choose ALL that apply.
Not Sure I would be too embarrassed to talk about it to an Strongly Agree )
( 16. Do you agree or disagree that harassment
adult Agree )
( Mother Other adults
and bullying by other students is a problem
I would be afraid people would think it was my Disagree )
( Father Sister(s)
at your school?
fault Strongly Disagree )
( Stepmother Brother(s) I would be afraid I would get in trouble )
( Stepfather Stepsister(s) Strongly Agree Disagree I do not think my report would be taken seriously )
( Grandmother(s) Stepbrother(s) Agree Strongly Disagree and nothing would be done )
( Grandfather(s) Other children Neutral )
( Foster parent )
( )
( )
( ] ]] ] ] 2
] ] ] 15
] ]] ] )
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)
)
Think about the people who know you well. How The next section asks about your experiences related 17. My teacher notices when I am doing a good How many times have you: )
do you think they would rate you on each of these? to civic engagement. job and lets me know about it.
24. …participated in school or non-school- )
During the last 12 months, how many times @@@@
NO!! @@@@
no @@@@
yes YES!!
based activities after the regular school day )
People who know me would say this: )
have you: ended (e.g., sports, clubs, art or music
152. Giving up when things get hard for me is … 18. I feel safe at my school. groups, student government, scouting, etc.)? )
157. …been a leader in a group or organization? )
Not at all like me @@@@
NO!! @@@@
no @@@@
yes YES!! Never )
A little like me Never 3-4 times I’ve done it, but not in the past year )
Somewhat like me Once 5 or more times Less than once a month )
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Quite like me Twice 19. There are lots of chances for students at my About once a month )
Very much like me school to talk with a teacher one-on-one. Two or three times a month )
@@@@
NO!! @@@@
no @@@@
yes YES!! Once a week or more )
158. …helped make sure that all people are
treated fairly? )
153. Knowing how to say "no" when someone )
wants me to do things I know are wrong or 20. The school lets my parents know when I 25. …volunteered to do community service?
Never 3-4 times
have done something well. )
dangerous is … Once 5 or more times Never )
Not at all like me Twice @@@@
NO!! @@@@
no @@@@
yes YES!! I’ve done it, but not in the past year )
A little like me Less than once a month )
Somewhat like me
159. …stood up for what you believed, even The next section asks about how you spend your
About once a month )
Quite like me
when it was unpopular to do so?
Two or three times a month )
Very much like me time after school. Once a week or more )
Never 3-4 times )
Once 5 or more times )
154. Thinking through the possible good and bad Twice On an average school day, how many hours do you: On an average school day, how many hours do )
results of different choices before I make you spend: )
decisions is… The next section asks about sexual harassment and 21. …watch TV? )
Not at all like me sexual discrimination. Sexual harassment is unwanted Not at all 26. …doing homework outside of school? )
A little like me and unwelcome sexual behavior that interferes with Less than 1 hour per day None )
Somewhat like me someone’s life at school or any school sponsored 1 hour per day Half hour or less )
Quite like me activity (like band, sports, field trips, bus rides, or 2 hours per day Between a half hour and an hour )
Very much like me school activities/clubs). Sexual harassment includes 3 hours per day 1 hour )
unwelcome sexual advances, regardless of sexual 4 hours per day 2 hours )
orientation; requests for sexual favors; spreading 5 or more hours per day 3 hours or more )
How much do you agree or disagree with the sexual rumors; and other inappropriate verbal, )
following statements?: electronic, or physical conduct of a sexual nature. 22. …play video or computer games or use a )
Sexual harassment is NOT behaviors that a person computer for something that is not school 27. …going to work? )
155. I get along well with students who are likes or wants or is agreed to between two people (for work? (Count time spent playing games, None )
different from me. example, kissing, touching, flirting that you both agree watching videos, texting, or using social Half hour or less )
Strongly Agree to). Sexual discrimination is a verbal, electronic or media on your smartphone, computer, Xbox, Between a half hour and an hour )
Agree physical action that denigrates or shows hostility PlayStation, iPad, or other tablet.) 1 hour )
Not Sure towards an individual because of his or her sex, sexual
Not at all
2 hours )
Disagree orientation, or gender identification. Both sexual
Less than 1 hour per day
3 hours or more )
Strongly Disagree harassment and sexual discrimination may create an
1 hour per day )
intimidating, hostile, or offensive learning
2 hours per day )
environment for the victim and/or bystanders. 28. …staying after school to participate in a )
156. I know how to disagree without starting an 3 hours per day team, club, program, etc.?
4 hours per day )
argument or fight. None )
How many times in the past year: 5 or more hours per day
Strongly Agree Half hour or less )
Agree
160. …has another student sexually harassed
Between a half hour and an hour )
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Not Sure 23. Are there sports teams or other after-school 1 hour )
you? activities for people your age available in
Disagree 2 hours )
Strongly Disagree Never 10 to 19 times your community? 3 hours or more )
1 to 2 times 20 to 29 times @@@@
NO!! @@@@
no @@@@
yes YES!! )
3 to 5 times 30 to 39 times )
6 to 9 times 40 or more times )
)
)
)
)
PLEASE DO NOT WRITE IN THIS AREA PLEASE DO NOT WRITE IN THIS AREA
)
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)
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( )
( 29. …participating in a team, club, program, etc. 35. … Doing my best even when I have to do a 146. ...drink a can, bottle, or glass of a sports )
( 141. …eat fruit? (Do not count fruit juice.) )
somewhere other than at school? job I don't like. drink, such as Gatorade or PowerAde? (Do
( I did not eat fruit during the past 7 days
not count low-calorie sports drinks such as )
( None Extremely Important 1 to 3 times during the past 7 days )
Half hour or less Propel or G2.)
( Quite Important 4 to 6 times during the past 7 days )
( Between a half hour and an hour Not Sure 1 time per day I did not drink sports drinks during the past 7 days )
( 1 hour Somewhat Important 2 times per day 1 to 3 times during the past 7 days )
( 2 hours Not Important 3 times per day 4 to 6 times during the past 7 days )
( 3 hours or more 4 or more times per day 1 time per day )
( 2 times per day )
How much do you agree or disagree with the 3 times per day
( 30. How often do you attend religious services following? )
( 142. …eat vegetables? 4 or more times per day )
or activities?
( 36. … When things don't go well for me, I am I did not eat eat vegetables during the past 7 days )
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( Never 1 to 3 times during the past 7 days )
Rarely good at finding a way to make things better. During the past 30 days, did you:
( 4 to 6 times during the past 7 days )
( 1-2 times a month Strongly Agree 1 time per day )
About once a week or more 147. …go without eating for 24 hours or more
( Agree 2 times per day
(also called fasting) to lose weight or to keep )
( Not Sure 3 times per day
from gaining weight? )
( The next section asks about your feelings and
Disagree 4 or more times per day )
( Strongly Disagree Yes No )
experiences in other parts of your life. Remember, your
( answers are confidential.
)
( 143. …drink a can, bottle, or glass of soda or )
37. … I feel as if I can solve most problems in pop (such as Coke, Pepsi, or Sprite)? Do not 148. …take any diet pills, powders, or liquids
( my life. without a doctor's advice to lose weight or )
( include diet soda or diet pop. )
31. I ignore rules that get in my way. to keep from gaining weight? Do not include
( Strongly Agree I did not drink soda or pop during the past 7 days
meal replacement products (such as Slim Fast). )
( Very false Agree 1 to 3 times during the past 7 days )
( Somewhat false Not Sure 4 to 6 times during the past 7 days Yes No )
( Somewhat true Disagree 1 time per day )
( Very true Strongly Disagree 2 times per day )
149. …vomit or take laxatives to lose weight or to
( 3 times per day
keep from gaining weight? )
( 32. There are lots of adults in my neighborhood I 38. …I have much in life to be thankful for. 4 or more times per day )
( Yes No )
could talk to about something important.
( Strongly Agree )
( NO!! no yes YES!! Agree 144. …drink a can, bottle, or glass of a sugar- )
sweetened beverage such as lemonade, The next section asks about physical activity.
( Not Sure )
( Disagree sweetened tea or coffee drinks, flavored )
33. My neighbors notice when I am doing a milk, Snapple, or Sunny Delight? (Do not
( good job and let me know about it.
Strongly Disagree
150. During the past 7 days, on how many days )
( count soda or pop, sports drinks, energy )
NO!! no yes YES!! drinks, or 100% fruit juice.) were you physically active for a total of at
( How much do you do the following when you least 60 minutes per day? Add up all the time you )
( have a problem of any kind? I did not drink sugar-sweetened beverages during
spend in any kind of physical activity that increases your )
( How important is each of the following to you the past 7 days
heart rate and makes you breathe hard some of the time. )
( in your life? 39. I try to find different solutions to the 1 to 3 times during the past 7 days )
( 4 to 6 times during the past 7 days 0 days 3 days 6 days )
problem. 1 day 4 days 7 days
( 34. … Accepting responsibility for my actions 1 time per day )
( A lot 2 times per day 2 days 5 days )
when I make a mistake or get in trouble.
( Sometimes 3 times per day )
( Extremely Important A little 4 or more times per day )
Quite Important 151. On an average school night, how many
( Never )
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Not Sure hours of sleep do you get?
( )
( Somewhat Important 145. ...did you drink a can, bottle, or glass of an 4 or less hours 8 hours )
( Not Important energy drink, such as Red Bull or Jolt? (Do 5 hours 9 hours )
( not count diet energy drinks or sports drinks 6 hours 10 or more hours )
( such as Gatorade or PowerAde.) 7 hours )
( I did not drink energy drinks during the past 7 days )
( 1 to 3 times during the past 7 days )
( 4 to 6 times during the past 7 days )
( 1 time per day )
( 2 times per day )
( 3 times per day )
( 4 or more times per day )
( )
( ] ]] ] ] 4
] ] ] 13
] ]] ] )
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( )
( The next section asks about sexual behavior. 137. The last time you had sexual intercourse, did The next section asks about your family. When 47. When I am not at home, one of my parents )
( Remember, your answers are confidential. you or your partner use a condom? answering these questions, please think about the knows where I am and who I am with. )
( people you consider to be your family; for example, )
( 132. Have you ever had sexual intercourse? I have never had sexual intercourse parents, stepparents, grandparents, aunts, uncles, etc. @@@@
NO!! @@@@
no @@@@
yes YES!! )
Yes
( )
( @@@@@@ @@
Yes No No
)
How wrong do your parents feel it would be for 48. My family has clear rules about alcohol and
( you to: drug use. )
( 133. How old were you when you had sexual 138. The last time you had sexual intercourse, )
( @@@@
NO!! @@@@
no @@@@
yes YES!! )
intercourse for the first time? what one method did you or your partner 40. …drink beer, wine, or hard liquor (for
( )
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use to prevent pregnancy? Select only ONE example, vodka, whiskey, or gin) regularly
( I have never had sexual intercourse
response. (at least once or twice a month)? 49. People in my family often insult or yell at )
( 11 years old or younger
each other. )
( 12 years old I have never had sexual intercourse Very wrong )
( 13 years old No method was used to prevent pregnancy Wrong @@@@
NO!! @@@@
no @@@@
yes YES!! )
( 14 years old Birth control pills A little bit wrong )
( 15 years old Condoms Not wrong at all
50. My parent has had their body hurt from )
( 16 years old An IUD (such as Mirena or ParaGard) or implant
41. …smoke cigarettes? actions (such as punching, kicking, choking, )
( 17 years old or older (such as Implanon or Nexplanon)
shoving, and pulling of hair) by a )
( A shot (such as Depo-Provera), patch (such as Very wrong
spouse/partner. )
( 134. During your life, with how many people Ortho Evra), or birth control ring (such as Wrong )
( NuvaRing) A little bit wrong @@@@
NO!! @@@@
no @@@@
yes YES!! )
have you had sexual intercourse?
( Withdrawal or some other method Not wrong at all )
( I have never had sexual intercourse Not sure
42. …smoke marijuana? 51. If I had a personal problem, I could ask my )
( 1 person
mom or dad for help. )
( 2 people
139. Have you ever had oral sex?
Very wrong )
( 3 people Wrong @@@@
NO!! @@@@
no @@@@
yes YES!! )
( 4 people @@@@@@
Yes No A little bit wrong )
( 5 people Not wrong at all
52. My parents ask me what I think before most )
( 6 or more people The next section asks about food you ate or drank during 43. …vape? family decisions affecting me are made. )
( 135. During the past 3 months, with how many the past 7 days. Think about all the meals and snacks you )
( had from the time you got up until you went to bed. Be Very wrong @@@@
NO!! @@@@
no @@@@
yes YES!! )
people have you had sexual intercourse?
( sure to include food you ate at home, at school, at Wrong )
( I have never had sexual intercourse restaurants, or anywhere else. A little bit wrong The next section asks about things you might have done, or )
( I have had sexual intercourse but not during the Not wrong at all that might have happened to you. Some of the questions are )
( past 3 months
During the past 7 days, how many times did you: 44. How many times have you changed homes
about bullying. Bullying is when 1 or more students tease, )
( 1 person
since kindergarten?
threaten, spread rumors about, hit, shove, or hurt another )
( 2 people student over and over again. Bullying is any aggressive and )
140. …drink 100% fruit juices such as orange unwanted behavior that is intended to harm, intimidate, or
( 3 people juice, apple juice, or grape juice? (Do not None
humiliate the victim; involves a real or perceived power )
( 4 people count punch, Kool-Aid, sports drinks, or 1-2 times
imbalance between the aggressor or aggressors and victim; )
( 5 people other fruit-flavored drinks.) 3-4 times
and is repeated over time or causes severe emotional )
( 6 or more people
I did not drink 100% fruit juice during the past 7 days
5-6 times
trauma. It is not bullying when 2 students of about the )
( 1 to 3 times during the past 7 days
7 or more times
same strength or power argue or fight or tease each other )
( 136. Did you drink alcohol or use drugs before 4 to 6 times during the past 7 days 45. During the past 30 days, how often did you in a friendly way. “Bullying” does not include ordinary )
( you had sexual intercourse the last time? 1 time per day go hungry because there was not enough teasing, horseplay, argument, or peer conflict. )
( 2 times per day food in your home? )
( I have never had sexual intercourse
3 times per day
Remember, your answers are confidential. )
( Yes
4 or more times per day
Never )
( No Rarely
53. During the past 12 months, have you ever )
( Sometimes
bullied someone else on school property? )
( Most of the time )
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( Always @@@@@@
Yes @@
No )
( 46. I feel safe in my neighborhood, or the area )
( around where I live. 54. During the past 12 months, have you ever )
( bullied someone else away from school )
( NO!! no yes YES!!
property? )
( )
( @@@@@@
Yes @@
No )
( )
( )
( )
( PLEASE DO NOT WRITE IN THIS AREA PLEASE DO NOT WRITE IN THIS AREA
)
( ] ]] ] 12
] ] ] 5
] ] ]] ] )
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( )
( During the past 12 months, have you ever: How many times in the past year has anyone How easy or hard would it be for you to get: 128. …use LSD, cocaine, amphetamines, or )
( done any of the following TO YOU: another illegal drug? )
( 55. …been bullied on school property? 121. …some beer, wine, or hard liquor (for )
( 62. …said something bad about your race or example, vodka, whiskey, or gin)?
Very wrong )
( @@@@@@
Yes @@
No Wrong )
culture? Very hard
( A little bit wrong )
( 56. …been bullied away from school property? Never 10 to 19 times Sort of hard Not wrong at all )
( 1 to 2 times 20 to 29 times Sort of easy )
( @@@@@@ @@
Yes No 3 to 5 times 30 to 39 times Very easy )
6 to 9 times 40 or more times 129. How wrong would most adults in your
( neighborhood, or the area around where )
( During the past 30 days, on how many days 63. …sexually harassed you? 122. …some cigarettes? you live, think it is for kids your age to use )
( did you: marijuana? )
( Never 10 to 19 times Very hard )
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( 57. …carry a weapon such as a gun, knife, or 1 to 2 times 20 to 29 times Sort of hard Very wrong )
( 3 to 5 times 30 to 39 times Sort of easy Wrong )
club? 6 to 9 times 40 or more times Very easy
( A little bit wrong )
( 0 days Not wrong at all )
1 day 64. How many times in the past year has a
( parent or adult in your household bullied, 123. …drugs like cocaine, LSD, or )
( 2 or 3 days )
4 or 5 days taunted, ridiculed, or teased you? amphetamines?
( )
( 6 or more days Never 10 to 19 times Very hard The next section asks about prescription pain )
( 1 to 2 times 20 to 29 times Sort of hard relievers that you have used without a doctor’s order )
( 58. …carry a weapon such as a gun, knife, or 3 to 5 times 30 to 39 times Sort of easy in your lifetime. Examples of prescription pain )
( 6 to 9 times 40 or more times Very easy relievers include Oxycontin, Vicodin, Percocet, )
club on school property?
( 65. How often did a parent or adult in your
Codeine, Methadone, and Fentanyl. )
( 0 days )
1 day home ever hit, beat, kick, or physically hurt 124. …some marijuana? 130. What were the reasons you took a
( you in any way? Do not include spanking. prescription pain reliever without a doctor’s )
( 2 or 3 days Very hard
4 or 5 days Never 10 to 19 times Sort of hard order the last time? Choose ALL that apply. )
( )
( 6 or more days 1 to 2 times 20 to 29 times Sort of easy I did not take a prescription pain reliever without a )
( 3 to 5 times 30 to 39 times Very easy doctor’s order )
( 59. During the past 12 months, on how many 6 to 9 times 40 or more times To relieve physical pain )
( days did you carry a gun? (Do not count 66. Have you ever been physically forced to How wrong do you think it is for someone your
To relax or relieve tension )
( the days when you carried a gun only for have sexual intercourse when you did not age to:
To experiment or to see what it’s like )
( hunting or for a sport, such as target want to?
To feel good or get high )
( shooting.) 125. …drink beer, wine, or hard liquor (for
To help with my sleep )
( Yes No To help me with my feelings or emotions )
0 days example, vodka, whiskey, or gin) regularly
( 67. During the past 30 days, how many times (at least once or twice a month)?
To increase or decrease the effect(s) of some other drug )
( 1 day Because I am “hooked” or I have to have it )
2 or 3 days have you driven a car or other vehicle Very wrong
( when you had been drinking alcohol?
I used it for some other reason )
( 4 or 5 days Wrong )
( 6 or more days I did not drive a car or other vehicle during the A little bit wrong )
past 30 days Not wrong at all 131. How did you get the prescription pain
( reliever? If you got it in more than one way, )
( How many times in the past year have you: 0 times )
1 time please choose ONE of these ways as your
( 126. …smoke cigarettes? best answer. )
( 60. …said something bad about someone's 2 or 3 times )
( 4 or 5 times Very wrong I did not take a prescription pain reliever without a )
race or culture? 6 or more times Wrong
( doctor’s order )
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( @@@@@@@@
Never 10 to 19 times A little bit wrong I got a prescription from just one doctor )
@@@@@@@@
1 to 2 times 20 to 29 times 68. During the past 30 days, on how many days Not wrong at all
( did you text or e-mail while driving a car or
I got prescriptions from more than one doctor )
( @@@@@@@@
3 to 5 times 30 to 39 times I stole it from a doctor’s office, clinic, hospital, or )
@@@@@@@@
6 to 9 times 40 or more times other vehicle?
( 127. …smoke marijuana?
pharmacy )
( I did not drive a car or other vehicle during the I got it from a friend or relative for free )
( 61. …been suspended from school? past 30 days Very wrong I bought it from a friend or relative )
( 0 days Wrong I took it from a friend or relative without asking )
( @@@@@@@@
Never 10 to 19 times 1 or 2 days A little bit wrong I bought it from a drug dealer or other stranger )
( @@@@@@@@
1 to 2 times 20 to 29 times 3 to 5 days Not wrong at all I got it in some other way )
( @@@@@@@@
3 to 5 times 30 to 39 times 6 to 9 days )
( @@@@@@@@
6 to 9 times 40 or more times 10 to 19 days )
( 20 to 29 days )
( All 30 days )
( ] ]] ] ] ] ] ] 11
] ] ] ] )
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( )
( 107. … used cabeniferol (cabbies) in the past 30 114. …taken a prescription drug other than 69. During the past 30 days, have you ever 76. …force you to do sexual things that you did )
( days? painkillers (such as Ritalin, Adderall, or nodded off or fallen asleep, even just for a not want to do? (Count such things as )
( Xanax) without a doctor's order in the past brief moment, while driving? kissing, touching, or being physically forced )
( @@@@@@@@
0 occasions 10-19 occasions )
@@@@@@@@ 30 days? to have sexual intercourse.)
( 1-2 occasions 20-39 occasions I did not drive a car or other vehicle during the )
( @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@@
0 occasions 10-19 occasions past 30 days I did not date or go out with anyone during the )
( @@@@@
6-9 occasions @@@@@@@@
1-2 occasions 20-39 occasions 0 days past 12 months )
( @@@@@@@@
3-5 occasions 40 or more occasions 1 or 2 days 0 times )
( 108. …used LSD or other hallucinogens (acid, @6-9 occasions 3 to 5 days 1 time )
( 6 to 9 days 2 or 3 times )
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angel dust, special k, shrooms) in the past 30
( days? 115. …used Ecstasy in the past 30 days?
10 to 19 days 4 or 5 times )
( 20 to 29 days 6 or more times )
( @@@@@@@@
0 occasions 10-19 occasions @@@@@@@@
0 occasions 10-19 occasions All 30 days )
( @@@@@@@@ @@@@@@@@
The next section asks about electronic bullying, also )
1-2 occasions 20-39 occasions 1-2 occasions 20-39 occasions
( @@@@@@@@ @@@@@@@@
known as cyberbullying. Electronic bullying is bullying )
3-5 occasions 40 or more occasions 3-5 occasions 40 or more occasions 70. Have you ever belonged to a gang?
( @@@@@ @
through e-mail, chat rooms, texting, Instagram, )
6-9 occasions 6-9 occasions
Yes No
( Facebook, or other social media. )
( 109. …used cocaine or crack in the past 30 days? 116. …taken over-the-counter drugs to get high in 71. How old were you when you first belonged )
( the past 30 days? to a gang? )
( @@@@@@@@
0 occasions 10-19 occasions )
@@@@@@@@ @@@@@@@@ 77. During the past 12 months, have you ever
( 1-2 occasions 20-39 occasions 0 occasions 10-19 occasions Never have 14
been electronically bullied? (Count being )
( @@@@@@@@ @@@@@@@@
bullied through texting, Instagram, Facebook, )
3-5 occasions 40 or more occasions 1-2 occasions 20-39 occasions 10 or younger 15
( @@@@@
6-9 occasions @@@@@@@@
3-5 occasions 40 or more occasions 11 16 )
@ or other social media.)
( 6-9 occasions 12 17 or older )
( 110. …used methamphetamine (speed, crystal, 13 Yes No )
( crank, or ice) in the past 30 days? How old were you when you first: 78. How many times in the past year have you )
( Have you ever had a partner in a dating or
been cyberbullied by a student who attends )
( @@@@@@@@
0 occasions 10-19 occasions serious relationship who: )
@@@@@@@@ 117. …smoked a cigarette, even just a puff? your school?
( 1-2 occasions 20-39 occasions )
( @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@
Never have @@@@@
12 15 72. …always wanted to know your whereabouts? Never 10 to 19 times )
( @@@@@
6-9 occasions @@@@@@@ @@@@@ 16
10 or younger 13
Yes No
1 to 2 times 20 to 29 times )
( @@@@@@@
11 @@@@@
14 17 or older 3 to 5 times 30 to 39 times )
( 111. …taken steroids without a doctor's order in 73. …called you names or put you down
6 to 9 times 40 or more times )
( the past 30 days? 118. …had more than a sip or two of beer, wine, verbally? 79. How many times in the past year have you )
( or hard liquor (for example, vodka, whiskey, cyberbullied a student attending your school? )
( @@@@@@@@
0 occasions 10-19 occasions Yes No )
@@@@@@@@ or gin)?
( 1-2 occasions 20-39 occasions Never 10 to 19 times )
( @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@
Never have @@@@@
12 15 74. …pressured you into having sex (going all 1 to 2 times 20 to 29 times )
( @@@@@
6-9 occasions @@@@@@@ @@@@@ 16
10 or younger 13 the way) when you didn’t want to? 3 to 5 times 30 to 39 times )
( @@@@@@@
11 @@@@@
14 17 or older
Yes No
6 to 9 times 40 or more times )
( 112. …used heroin in the past 30 days? )
( 119. …began drinking alcoholic beverages During the past 12 months, how many times did 80. I have the right to say anything I want online, )
( @@@@@@@@
even if what I say hurts someone or violates )
0 occasions 10-19 occasions
@@@@@@@@ regularly, that is, at least once or twice a someone you were dating or going out with:
( 1-2 occasions 20-39 occasions
month? someone's privacy. )
( @@@@@@@@
3-5 occasions 40 or more occasions )
@@@@@ @@@@@@@ @@@@@ 75. …physically hurt you on purpose? (Count
( 6-9 occasions Never have 12 15
such things as being hit, slammed into
Strongly Agree )
( @@@@@@@ @@@@@ 16
10 or younger 13 Agree )
@@@@@@@ @@@@@ something, or injured with an object or
( 113. …taken painkillers (such as Oxycontin, 11 14 17 or older
weapon.)
Disagree )
( Vicodin, Percocet, Codeine, and Opium)
Strongly Disagree )
( without a doctor's order in the past 30 days? 120. …smoked marijuana?
I did not date or go out with anyone during the )
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( past 12 months )
( @@@@@@@@
0 occasions 10-19 occasions @@@@@@@
Never have @@@@@
12 15 0 times )
( @@@@@@@@
1-2 occasions 20-39 occasions @@@@@@@ @@@@@ 16
10 or younger 13 1 time )
( @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@
11 @@@@@
14 17 or older 2 or 3 times )
( @@@@@
6-9 occasions 4 or 5 times )
( 6 or more times )
( )
( )
( )
( )
( PLEASE DO NOT WRITE IN THIS AREA PLEASE DO NOT WRITE IN THIS AREA
)
( ] ]] ] 10
] ] ] ]7 ] ]] ] )
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( )
( The next section asks about your feelings during 87. …smoke marijuana regularly? On how many occasions (if any) have you: 101. During the past 30 days, how did you )
( the past 12 months. usually get the alcohol you drank? )
( Remember, your answers are confidential. No risk )
Slight risk 94. …vaped nicotine during the past 30 days?
( I did not drink alcohol during the past 30 days )
(During the past 12 months, did you ever: Moderate risk @@@@@@@@
0 occasions 10-19 occasions I bought it in a store such as a liquor store, )
( Great risk @@@@@@@@
1-2 occasions 20-39 occasions convenience store, supermarket, discount store, or )
( 81. …feel so sad or hopeless almost every day @@@@@@@@
3-5 occasions 40 or more occasions gas station )
( 88. …take one or two drinks of an alcoholic 6-9 occasions I bought it at a restaurant, bar, or a club )
for two weeks or more in a row that you beverage (beer, wine, liquor) nearly every
( stopped doing some usual activities? I bought it at a public event such as a concert or )
( day? sporting event )
Yes No 95. …vaped marijuana during the past 30 days?
( No risk I gave someone else money to buy it for me )
( 82. …seriously consider attempting suicide? Slight risk @@@@@@@@
0 occasions 10-19 occasions Someone gave it to me )
( Moderate risk @@@@@@@@
1-2 occasions 20-39 occasions I took it from a store or family member )
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( Yes No Great risk @@@@@@@@
3-5 occasions 40 or more occasions @@
I got it some other way )
( 83. During the past 12 months, how many @@@@@
6-9 occasions )
( times did you actually attempt suicide? 89. How frequently have you used smokeless On how many occasions (if any) have you: )
( tobacco (snuff, plug, dipping tobacco, 96. …vaped flavoring, without any nicotine or )
( 0 times 4 or 5 times chewing tobacco, snus, dissolvable marijuana in it during the past 30 days? 102. …used marijuana in your lifetime? )
( 1 time 6 or more times tobacco) during the past 30 days? )
( 2 or 3 times
Never @@@@@@@@
0 occasions 10-19 occasions @@@@@@@@
0 occasions 10-19 occasions )
( @@@@@@@@
1-2 occasions 20-39 occasions @@@@@@@@
1-2 occasions 20-39 occasions )
( 84. Stress means a situation in which a person
Once or twice
Once in a while but not regularly @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@@
3-5 occasions 40 or more occasions )
( feels tense, restless, nervous, or anxious, or is
About once a day @@@@@
6-9 occasions @@@@@
6-9 occasions )
( unable to sleep at night because their mind is )
troubled all the time. Within the last 30 days, More than once a day
( During the last 30 days, on how many days 103. …used marijuana during the past 30 days? )
( how often have you felt this kind of stress? )
90. Have you ever smoked cigarettes in your (if any) have you:
( None of the time lifetime? @@@@@@@@
0 occasions 10-19 occasions )
( A little of the time @@@@@@@@
1-2 occasions 20-39 occasions )
Never 97. …taken “synthetic marijuana” (“K2”, @@@@@@@@
( Some of the time
“Spice”) to get high?
3-5 occasions 40 or more occasions )
( Most of the time Once or twice @@@@@
6-9 occasions )
( All of the time Once in a while but not regularly @@@@@@
None 6-9 )
( Regularly in the past @@@@@@
1-2 10-19 )
Regularly now 104. …sniffed glue, breathed (huffed) the
( The next section asks about your thoughts @@@@@@
3-5 @@@
20-30
contents of an aerosol spray can, or inhaled )
( about and experiences with tobacco, alcohol, )
( and other drugs. 91. How often have you smoked cigarettes other gases or sprays in order to get high in
)
during the past 30 days? On how many occasions (if any) have you: your lifetime?
( )
( Not at all @@@@@@@@
0 occasions 10-19 occasions )
98. …had beer, wine, or hard liquor in your @@@@@@@@
( How much do you think people risk harming Less than one cigarette per day
lifetime (more than just a few sips)?
1-2 occasions 20-39 occasions )
( themselves (physically or in other ways) if they: One to five cigarettes per day @@@@@@@@
3-5 occasions 40 or more occasions )
( About one-half pack per day @@@@@@@@
0 occasions 10-19 occasions @@@@@
6-9 occasions )
( 85. …smoke one or more packs of cigarettes About one pack per day @@@@@@@@
1-2 occasions 20-39 occasions )
( per day? About one and one half packs per day @@@@@@@@
3-5 occasions 40 or more occasions )
105. …sniffed glue, breathed (huffed) the contents
( No risk Two or more packs per day @@@@@
6-9 occasions
of an aerosol spray can, or inhaled other )
( Slight risk
gases or sprays in order to get high in the )
( Moderate risk 92. On how many occasions (if any) have you 99. …had beer, wine, or hard liquor during the past 30 days? )
( Great risk smoked tobacco using a hookah (water pipe) past 30 days? )
( during the past 30 days? @@@@@@@@
0 occasions 10-19 occasions )
( 86. …try marijuana once or twice? @@@@@@@@ @@@@@@@@
1-2 occasions 20-39 occasions )
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0 occasions 10-19 occasions
0 occasions 10-19 occasions
( No risk 1-2 occasions 20-39 occasions @@@@@@@@
1-2 occasions 20-39 occasions @@@@@@@@
3-5 occasions 40 or more occasions )
( Slight risk 3-5 occasions 40 or more occasions @@@@@@@@
3-5 occasions 40 or more occasions @@@@@
6-9 occasions )
( Moderate risk 6-9 occasions @@@@@
6-9 occasions )
( Great risk 100. Think back over the last two weeks. 106. … used cabeniferol (cabbies) in your lifetime? )
( 93. To “vape” is to use a device such as a Howmany times have you had five or )
( vape-pen, an e-cigarette, an e-hookah, or @@@@@@@@
0 occasions 10-19 occasions )
morealcoholic drinks in a row? @@@@@@@@
( e-vaporizer to inhale a mist or vapor into the
1-2 occasions 20-39 occasions )
( lungs. Have you ever vaped? @@@@@@
None 3-5 times @@@@@@@@
3-5 occasions 40 or more occasions )
( @@@@@@
Once 6-9 times @@@@@
6-9 occasions )
( Yes No @@@@@@
Twice @@@
10 or more times )
( )
( )
( )
( ] ]] ] 8
] ] ] ] 9
] ]] ] )
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( )
( The next section asks about your feelings during 87. …smoke marijuana regularly? On how many occasions (if any) have you: 101. During the past 30 days, how did you )
( the past 12 months. usually get the alcohol you drank? )
( Remember, your answers are confidential. No risk )
Slight risk 94. …vaped nicotine during the past 30 days?
( I did not drink alcohol during the past 30 days )
(During the past 12 months, did you ever: Moderate risk @@@@@@@@
0 occasions 10-19 occasions I bought it in a store such as a liquor store, )
( Great risk @@@@@@@@
1-2 occasions 20-39 occasions convenience store, supermarket, discount store, or )
( 81. …feel so sad or hopeless almost every day @@@@@@@@
3-5 occasions 40 or more occasions gas station )
( 88. …take one or two drinks of an alcoholic 6-9 occasions I bought it at a restaurant, bar, or a club )
for two weeks or more in a row that you beverage (beer, wine, liquor) nearly every
( stopped doing some usual activities? I bought it at a public event such as a concert or )
( day? sporting event )
Yes No 95. …vaped marijuana during the past 30 days?
( No risk I gave someone else money to buy it for me )
( 82. …seriously consider attempting suicide? Slight risk @@@@@@@@
0 occasions 10-19 occasions Someone gave it to me )
( Moderate risk @@@@@@@@
1-2 occasions 20-39 occasions I took it from a store or family member )
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( Yes No Great risk @@@@@@@@
3-5 occasions 40 or more occasions @@
I got it some other way )
( @@@@@
6-9 occasions )
( 83. During the past 12 months, how many 89. How frequently have you used smokeless On how many occasions (if any) have you: )
( times did you actually attempt suicide? )
tobacco (snuff, plug, dipping tobacco, 96. …vaped flavoring, without any nicotine or
( 0 times 4 or 5 times chewing tobacco, snus, dissolvable marijuana in it during the past 30 days? 102. …used marijuana in your lifetime? )
( 1 time 6 or more times tobacco) during the past 30 days? )
( 2 or 3 times
Never @@@@@@@@
0 occasions 10-19 occasions @@@@@@@@
0 occasions 10-19 occasions )
( Once or twice @@@@@@@@
1-2 occasions 20-39 occasions @@@@@@@@
1-2 occasions 20-39 occasions )
( 84. Stress means a situation in which a person Once in a while but not regularly @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@@
3-5 occasions 40 or more occasions )
( feels tense, restless, nervous, or anxious, or is
About once a day @@@@@
6-9 occasions @@@@@
6-9 occasions )
( unable to sleep at night because their mind is )
troubled all the time. Within the last 30 days, More than once a day
( During the last 30 days, on how many days 103. …used marijuana during the past 30 days? )
( how often have you felt this kind of stress? )
90. Have you ever smoked cigarettes in your (if any) have you:
( None of the time
lifetime? @@@@@@@@
0 occasions 10-19 occasions )
( A little of the time @@@@@@@@
1-2 occasions 20-39 occasions )
Never 97. …taken “synthetic marijuana” (“K2”, @@@@@@@@
( Some of the time
“Spice”) to get high?
3-5 occasions 40 or more occasions )
( Most of the time Once or twice @@@@@
6-9 occasions )
( All of the time Once in a while but not regularly @@@@@@
None 6-9 )
( Regularly in the past @@@@@@
1-2 10-19
104. …sniffed glue, breathed (huffed) the )
( The next section asks about your thoughts Regularly now @@@@@@
3-5 @@@
20-30
contents of an aerosol spray can, or inhaled )
( about and experiences with tobacco, alcohol, other gases or sprays in order to get high in )
( and other drugs. 91. How often have you smoked cigarettes )
during the past 30 days? On how many occasions (if any) have you: your lifetime?
( )
( Not at all @@@@@@@@
0 occasions 10-19 occasions )
98. …had beer, wine, or hard liquor in your @@@@@@@@
( How much do you think people risk harming Less than one cigarette per day
lifetime (more than just a few sips)?
1-2 occasions 20-39 occasions )
( themselves (physically or in other ways) if they: One to five cigarettes per day @@@@@@@@
3-5 occasions 40 or more occasions )
( About one-half pack per day @@@@@@@@
0 occasions 10-19 occasions @@@@@
6-9 occasions )
( 85. …smoke one or more packs of cigarettes About one pack per day @@@@@@@@ 20-39 occasions
1-2 occasions )
( per day? About one and one half packs per day @@@@@@@@
3-5 occasions 40 or more occasions
105. …sniffed glue, breathed (huffed) the contents )
( No risk Two or more packs per day @@@@@
6-9 occasions
of an aerosol spray can, or inhaled other )
( Slight risk gases or sprays in order to get high in the )
( Moderate risk 92. On how many occasions (if any) have you 99. …had beer, wine, or hard liquor during the past 30 days? )
( Great risk smoked tobacco using a hookah (water pipe) past 30 days? )
( during the past 30 days? @@@@@@@@
0 occasions 10-19 occasions )
( 86. …try marijuana once or twice? @@@@@@@@ @@@@@@@@
1-2 occasions 20-39 occasions )
aab
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0 occasions 10-19 occasions
0 occasions 10-19 occasions
( No risk 1-2 occasions 20-39 occasions @@@@@@@@
1-2 occasions 20-39 occasions @@@@@@@@
3-5 occasions 40 or more occasions )
( Slight risk 3-5 occasions 40 or more occasions @@@@@@@@
3-5 occasions 40 or more occasions @@@@@
6-9 occasions )
( Moderate risk 6-9 occasions @@@@@
6-9 occasions )
( Great risk 100. Think back over the last two weeks. 106. … used cabeniferol (cabbies) in your lifetime? )
( 93. To “vape” is to use a device such as a How many times have you had five or )
( vape-pen, an e-cigarette, an e-hookah, or @@@@@@@@
0 occasions 10-19 occasions )
more alcoholic drinks in a row? @@@@@@@@
( e-vaporizer to inhale a mist or vapor into the
1-2 occasions 20-39 occasions )
( lungs. Have you ever vaped? @@@@@@
None 3-5 times @@@@@@@@
3-5 occasions 40 or more occasions )
( @@@@@@ 6-9 times
Once @@@@@
6-9 occasions )
( Yes No @@@@@@
Twice @@@
10 or more times )
( )
( )
( )
( ] ]] ] 8
] ] ] ] 9
] ]] ] )
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( )
( 107. … used cabeniferol (cabbies) in the past 30 114. …taken a prescription drug other than 69. During the past 30 days, have you ever 76. …force you to do sexual things that you did )
( days? painkillers (such as Ritalin, Adderall, or nodded off or fallen asleep, even just for a not want to do? (Count such things as )
( Xanax) without a doctor's order in the past brief moment, while driving? kissing, touching, or being physically forced )
( @@@@@@@@
0 occasions 10-19 occasions )
@@@@@@@@ 30 days? to have sexual intercourse.)
( 1-2 occasions 20-39 occasions I did not drive a car or other vehicle during the )
( @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@@
0 occasions 10-19 occasions past 30 days I did not date or go out with anyone during the )
( @@@@@
6-9 occasions @@@@@@@@
1-2 occasions 20-39 occasions 0 days past 12 months )
( @@@@@@@@
3-5 occasions 40 or more occasions 1 or 2 days 0 times )
( 108. …used LSD or other hallucinogens (acid, @6-9 occasions 3 to 5 days 1 time )
( 6 to 9 days 2 or 3 times )
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angel dust, special k, shrooms) in the past 30
( days? 115. …used Ecstasy in the past 30 days?
10 to 19 days 4 or 5 times )
( 20 to 29 days 6 or more times )
( @@@@@@@@
0 occasions 10-19 occasions @@@@@@@@
0 occasions 10-19 occasions All 30 day )
( @@@@@@@@ @@@@@@@@
The next section asks about electronic bullying, also )
1-2 occasions 20-39 occasions 1-2 occasions 20-39 occasions
( @@@@@@@@ @@@@@@@@
known as cyberbullying. Electronic bullying is bullying )
3-5 occasions 40 or more occasions 3-5 occasions 40 or more occasions 70. Have you ever belonged to a gang?
( @@@@@ @
through e-mail, chat rooms, texting, Instagram, )
6-9 occasions 6-9 occasions
Yes No
( Facebook, or other social media. )
( 109. …used cocaine or crack in the past 30 days? 116. …taken over-the-counter drugs to get high in 71. How old were you when you first belonged )
( the past 30 days? to a gang? )
( @@@@@@@@
0 occasions 10-19 occasions )
@@@@@@@@ @@@@@@@@ 77. During the past 12 months, have you ever
( 1-2 occasions 20-39 occasions 0 occasions 10-19 occasions Never have 14
been electronically bullied? (Count being )
( @@@@@@@@ @@@@@@@@
bullied through texting, Instagram, Facebook, )
3-5 occasions 40 or more occasions 1-2 occasions 20-39 occasions 10 or younger 15
( @@@@@
6-9 occasions @@@@@@@@
3-5 occasions 40 or more occasions 11 16 )
@ or other social media.)
( 6-9 occasions 12 17 or older )
( 110. …used methamphetamine (speed, crystal, 13 Yes No )
( crank, or ice) in the past 30 days? How old were you when you first: 78. How many times in the past year have you )
( Have you ever had a partner in a dating or
been cyberbullied by a student who attends )
( @@@@@@@@
0 occasions 10-19 occasions serious relationship who: )
@@@@@@@@ 117.…smoked a cigarette, even just a puff? your school?
( 1-2 occasions 20-39 occasions )
( @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@
Never have @@@@@
12 15 72. …always wanted to know your whereabouts? Never 10 to 19 times )
( @@@@@
6-9 occasions @@@@@@@ @@@@@ 16
10 or younger 13
Yes No
1 to 2 times 20 to 29 times )
( @@@@@@@
11 @@@@@
14 17 or older 3 to 5 times 30 to 39 times )
( 111. …taken steroids without a doctor's order in 73. …called you names or put you down
6 to 9 times 40 or more times )
( the past 30 days? 118. …had more than a sip or two of beer, wine, verbally? 79. How many times in the past year have you )
( or hard liquor (for example, vodka, whiskey, cyberbullied a student attending your school? )
( @@@@@@@@
0 occasions 10-19 occasions Yes No )
@@@@@@@@ or gin)?
( 1-2 occasions 20-39 occasions Never 10 to 19 times )
( @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@
Never have @@@@@
12 15 74. …pressured you into having sex (going all 1 to 2 times 20 to 29 times )
( @@@@@
6-9 occasions @@@@@@@ @@@@@ 16
10 or younger 13 the way) when you didn’t want to? 3 to 5 times 30 to 39 times )
( @@@@@@@
11 @@@@@
14 17 or older
Yes No
6 to 9 times 40 or more times )
( 112. …used heroin in the past 30 days? )
( 119. …began drinking alcoholic beverages During the past 12 months, how many times did 80. I have the right to say anything I want online, )
( @@@@@@@@
even if what I say hurts someone or violates )
0 occasions 10-19 occasions
@@@@@@@@ regularly, that is, at least once or twice a someone you were dating or going out with:
( 1-2 occasions 20-39 occasions
month? someone's privacy. )
( @@@@@@@@
3-5 occasions 40 or more occasions )
@@@@@ @@@@@@@ @@@@@ 75. …physically hurt you on purpose? (Count
( 6-9 occasions Never have 12 15
such things as being hit, slammed into
Strongly Agree )
( @@@@@@@ @@@@@ 16
10 or younger 13 Agree )
@@@@@@@ @@@@@ something, or injured with an object or
( 113. …taken painkillers (such as Oxycontin, 11 14 17 or older
weapon.)
Disagree )
( Vicodin, Percocet, Codeine, and Opium)
Strongly Disagree )
( without a doctor's order in the past 30 days? 120. …smoked marijuana?
I did not date or go out with anyone during the )
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( past 12 months )
( @@@@@@@@
0 occasions 10-19 occasions @@@@@@@
Never have @@@@@
12 15 0 times )
( @@@@@@@@
1-2 occasions 20-39 occasions @@@@@@@ @@@@@ 16
10 or younger 13 1 time )
( @@@@@@@@
3-5 occasions 40 or more occasions @@@@@@@
11 @@@@@
14 17 or older 2 or 3 times )
( @@@@@
6-9 occasions 4 or 5 times )
( 6 or more times )
( )
( )
( )
( )
( PLEASE DO NOT WRITE IN THIS AREA PLEASE DO NOT WRITE IN THIS AREA
)
( ] ]] ] 10
] ] ] ]7 ] ]] ] )
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( )
( During the past 12 months, have you ever: How many times in the past year has anyone How easy or hard would it be for you to get: 128. …use LSD, cocaine, amphetamines, or )
( done any of the following TO YOU: another illegal drug? )
( 55. …been bullied on school property? 121. …some beer, wine, or hard liquor (for )
( 62. …said something bad about your race or example, vodka, whiskey, or gin)?
Very wrong )
( @@@@@@
Yes @@
No Wrong )
culture? Very hard
( A little bit wrong )
( Never 10 to 19 times Sort of hard Not wrong at all )
56. …been bullied away from school property? 1 to 2 times 20 to 29 times Sort of easy
( )
( @@@@@@
Yes @@
No 3 to 5 times 30 to 39 times Very easy )
6 to 9 times 40 or more times 129. How wrong would most adults in your
( neighborhood, or the area around where )
( During the past 30 days, on how many days 63. …sexually harassed you? 122. …some cigarettes? you live, think it is for kids your age to use )
( did you: marijuana? )
( Never 10 to 19 times Very hard )
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( 1 to 2 times 20 to 29 times Sort of hard Very wrong )
57. …carry a weapon such as a gun, knife, or 3 to 5 times 30 to 39 times Sort of easy
( club?
Wrong )
( 6 to 9 times 40 or more times Very easy A little bit wrong )
( 0 days Not wrong at all )
1 day 64. How many times in the past year has a
( parent or adult in your household bullied, 123. …drugs like cocaine, LSD, or )
( 2 or 3 days )
4 or 5 days taunted, ridiculed, or teased you? amphetamines?
( )
6 or more days Never 10 to 19 times Very hard The next section asks about prescription pain
( )
1 to 2 times 20 to 29 times Sort of hard relievers that you have used without a doctor’s order
( )
3 to 5 times 30 to 39 times Sort of easy in your lifetime. Examples of prescription pain
( 58. …carry a weapon such as a gun, knife, or )
6 to 9 times 40 or more times Very easy relievers include Oxycontin, Vicodin, Percocet,
( club on school property? )
Codeine, Methadone, and Fentanyl.
( 65. How often did a parent or adult in your )
( 0 days )
1 day home ever hit, beat, kick, or physically hurt 124. …some marijuana?
( you in any way? Do not include spanking. 130. What were the reasons you took a )
( 2 or 3 days Very hard
prescription pain reliever without a doctor’s )
( 4 or 5 days Never 10 to 19 times Sort of hard
order the last time? Choose ALL that apply. )
( 6 or more days 1 to 2 times 20 to 29 times Sort of easy
3 to 5 times 30 to 39 times Very easy I did not take a prescription pain reliever without a )
( doctor’s order )
( 6 to 9 times 40 or more times )
59. During the past 12 months, on how many To relieve physical pain
( days did you carry a gun? (Do not count 66. Have you ever been physically forced to How wrong do you think it is for someone your To relax or relieve tension )
( the days when you carried a gun only for have sexual intercourse when you did not age to: To experiment or to see what it’s like )
( hunting or for a sport, such as target want to? To feel good or get high )
( shooting.) 125. …drink beer, wine, or hard liquor (for To help with my sleep )
( Yes No )
0 days example, vodka, whiskey, or gin) regularly To help me with my feelings or emotions
( 67. During the past 30 days, how many times (at least once or twice a month)? To increase or decrease the effect(s) of some other drug )
( 1 day )
2 or 3 days have you driven a car or other vehicle Very wrong Because I am “hooked” or I have to have it
( when you had been drinking alcohol? I used it for some other reason )
( 4 or 5 days Wrong )
( 6 or more days I did not drive a car or other vehicle during the A little bit wrong )
( past 30 days Not wrong at all 131. How did you get the prescription pain )
( 0 times reliever? If you got it in more than one )
How many times in the past year have you: 1 time
( 126. …smoke cigarettes? way, please choose ONE of these ways )
( 2 or 3 times as your best answer. )
60. …said something bad about someone's 4 or 5 times Very wrong
( race or culture? I did not take a prescription pain reliever without a )
( 6 or more times Wrong )
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Never 10 to 19 times A little bit wrong doctor’s order
( 68. During the past 30 days, on how many days I got a prescription from just one doctor )
( @@@@@@@@
1 to 2 times 20 to 29 times Not wrong at all )
@@@@@@@@
3 to 5 times 30 to 39 times did you text or e-mail while driving a car or I got prescriptions from more than one doctor
( other vehicle? I stole it from a doctor’s office, clinic, hospital, or )
( @@@@@@@@
6 to 9 times 40 or more times )
I did not drive a car or other vehicle during the 127. …smoke marijuana? pharmacy
( I got it from a friend or relative for free )
( past 30 days Very wrong )
61. …been suspended from school? 0 days Wrong I bought it from a friend or relative
( I took it from a friend or relative without asking )
( @@@@@@@@
Never 10 to 19 times 1 or 2 days A little bit wrong )
@@@@@@@@ 20 to 29 times
1 to 2 times 3 to 5 days Not wrong at all I bought it from a drug dealer or other stranger
( I got it in some other way )
( @@@@@@@@
3 to 5 times 30 to 39 times 6 to 9 days )
( @@@@@@@@ 40 or more times
6 to 9 times 10 to 19 days )
( 20 to 29 days )
( All 30 days )
( ] ]] ] ] ] ] ] 11
] ] ] ] )
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( )
( The next section asks about sexual behavior. 137. The last time you had sexual intercourse, The next section asks about your family. When 47. When I am not at home, one of my parents )
( Remember, your answers are confidential. did you or your partner use a condom? answering these questions, please think about the knows where I am and who I am with. )
( people you consider to be your family; for example, )
I have never had sexual intercourse
( 132. Have you ever had sexual intercourse? parents, stepparents, grandparents, aunts, uncles, etc. @@@@
NO!! @@@@
no @@@@
yes YES!! )
Yes
( )
( @@@@@@ @@
Yes No No
)
How wrong do your parents feel it would be for 48. My family has clear rules about alcohol and
( you to: drug use. )
( 133. How old were you when you had sexual 138.The last time you had sexual intercourse, )
( intercourse for the first time? what one method did you or your partner 40. …drink beer, wine, or hard liquor (for @@@@
NO!! @@@@
no @@@@
yes YES!! )
( )
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use to prevent pregnancy? Select only ONE example, vodka, whiskey, or gin) regularly
( I have never had sexual intercourse
response. (at least once or twice a month)? 49. People in my family often insult or yell at )
( 11 years old or younger
each other. )
( 12 years old I have never had sexual intercourse Very wrong )
( 13 years old No method was used to prevent pregnancy Wrong @@@@
NO!! @@@@
no @@@@
yes YES!! )
( 14 years old Birth control pills A little bit wrong )
( 15 years old Condoms Not wrong at all
50. My parent has had his/her body hurt from )
( 16 years old An IUD (such as Mirena or ParaGard) or implant
41. …smoke cigarettes? actions (such as punching, kicking, choking, )
( 17 years old or older (such as Implanon or Nexplanon)
shoving, and pulling of hair) by a )
( A shot (such as Depo-Provera), patch (such as Very wrong
spouse/partner. )
( 134. During your life, with how many people Ortho Evra), or birth control ring (such as Wrong )
( have you had sexual intercourse?
NuvaRing) A little bit wrong @@@@
NO!! @@@@
no @@@@
yes YES!! )
( Withdrawal or some other method Not wrong at all )
( I have never had sexual intercourse Not sure
42. …smoke marijuana? 51. If I had a personal problem, I could ask my )
( 1 person
mom or dad for help. )
( 2 people
139. Have you ever had oral sex?
Very wrong )
( 3 people Wrong @@@@
NO!! @@@@
no @@@@
yes YES!! )
( 4 people @@@@@@
Yes No A little bit wrong )
( 5 people Not wrong at all
52. My parents ask me what I think before most )
( 6 or more people The next section asks about food you ate or drank during 43. …vape? family decisions affecting me are made. )
( 135. During the past 3 months, with how many the past 7 days. Think about all the meals and snacks you )
( people have you had sexual intercourse? had from the time you got up until you went to bed. Be Very wrong @@@@
NO!! @@@@
no @@@@
yes YES!! )
( sure to include food you ate at home, at school, at Wrong )
( I have never had sexual intercourse restaurants, or anywhere else. A little bit wrong The next section asks about things you might have done, or )
( I have had sexual intercourse but not during the Not wrong at all that might have happened to you. Some of the questions are )
( past 3 months
During the past 7 days, how many times did you: 44. How many times have you changed homes
about bullying. Bullying is when 1 or more students tease, )
( 1 person
since kindergarten?
threaten, spread rumors about, hit, shove, or hurt another )
( 2 people 140. …drink 100% fruit juices such as orange student over and over again. Bullying is any aggressive and )
unwanted behavior that is intended to harm, intimidate, or
( 3 people juice, apple juice, or grape juice? (Do not None
humiliate the victim; involves a real or perceived power )
( 4 people count punch, Kool-Aid, sports drinks, or 1-2 times
imbalance between the aggressor or aggressors and victim; )
( 5 people other fruit-flavored drinks.) 3-4 times
and is repeated over time or causes severe emotional )
( 6 or more people
I did not drink 100% fruit juice during the past 7 days
5-6 times
trauma. It is not bullying when 2 students of about the )
( 1 to 3 times during the past 7 days
7 or more times
same strength or power argue or fight or tease each other )
( 136. Did you drink alcohol or use drugs before 4 to 6 times during the past 7 days 45. During the past 30 days, how often did you in a friendly way. “Bullying” does not include ordinary )
( you had sexual intercourse the last time? 1 time per day go hungry because there was not enough teasing, horseplay, argument, or peer conflict. )
( 2 times per day food in your home? )
( I have never had sexual intercourse
3 times per day
Remember, your answers are confidential. )
( Yes
4 or more times per day
Never )
( No Rarely
53. During the past 12 months, have you ever )
( Sometimes
bullied someone else on school property? )
( Most of the time )
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( Always @@@@@@
Yes @@
No )
( 46. I feel safe in my neighborhood, or the area )
( around where I live. 54. During the past 12 months, have you ever )
( bullied someone else away from school )
( NO!! no yes YES!!
property? )
( )
( @@@@@@
Yes @@
No )
( )
( )
( )
( PLEASE DO NOT WRITE IN THIS AREA PLEASE DO NOT WRITE IN THIS AREA
)
( ] ]] ] 12
] ] ] 5
] ] ]] ] )
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( )
( 146. ...drink a can, bottle, or glass of a sports )
(
29. …participating in a team, club, program, etc. 35. … Doing my best even when I have to do a 141. …eat fruit? (Do not count fruit juice.) )
somewhere other than at school? job I don't like. drink, such as Gatorade or PowerAde? (Do
( I did not eat fruit during the past 7 days not count low-calorie sports drinks such as )
( None Extremely Important 1 to 3 times during the past 7 days )
Half hour or less Propel or G2.)
( Quite Important 4 to 6 times during the past 7 days )
( Between a half hour and an hour Not Sure 1 time per day I did not drink sports drinks during the past 7 days )
( 1 hour Somewhat Important 2 times per day 1 to 3 times during the past 7 days )
( 2 hours Not Important 3 times per day 4 to 6 times during the past 7 days )
( 3 hours or more 4 or more times per day 1 time per day )
( 2 times per day )
How much do you agree or disagree with the 3 times per day
( )
(
30. How often do you attend religious services following? 142. …eat vegetables? 4 or more times per day )
or activities?
( 36. … When things don't go well for me, I am I did not eat eat vegetables during the past 7 days )
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( Never 1 to 3 times during the past 7 days )
Rarely good at finding a way to make things better. During the past 30 days, did you:
( 4 to 6 times during the past 7 days )
( 1-2 times a month Strongly Agree )
About once a week or more
1 time per day 147. …go without eating for 24 hours or more
( Agree 2 times per day (also called fasting) to lose weight or to keep )
( Not Sure 3 times per day from gaining weight? )
( The next section asks about your feelings and
Disagree 4 or more times per day )
( Strongly Disagree Yes No )
experiences in other parts of your life. Remember, your
( )
(
answers are confidential. 143. …drink a can, bottle, or glass of soda or )
37. … I feel as if I can solve most problems in pop (such as Coke, Pepsi, or Sprite)? Do not 148. …take any diet pills, powders, or liquids
( my life. without a doctor's advice to lose weight or )
( include diet soda or diet pop. )
31. I ignore rules that get in my way. to keep from gaining weight? Do not include
( Strongly Agree I did not drink soda or pop during the past 7 days
meal replacement products (such as Slim Fast). )
( Very false Agree 1 to 3 times during the past 7 days )
( Somewhat false Not Sure 4 to 6 times during the past 7 days Yes No )
( Somewhat true Disagree 1 time per day )
( Very true Strongly Disagree 2 times per day )
149. …vomit or take laxatives to lose weight or to
( 3 times per day
keep from gaining weight? )
( 32. There are lots of adults in my neighborhood I 38. …I have much in life to be thankful for. 4 or more times per day )
( Yes No )
could talk to about something important.
( Strongly Agree )
( NO!! no yes YES!! Agree 144. …drink a can, bottle, or glass of a sugar- )
sweetened beverage such as lemonade, The next section asks about physical activity.
( Not Sure )
( Disagree sweetened tea or coffee drinks, flavored )
33. My neighbors notice when I am doing a milk, Snapple, or Sunny Delight? (Do not
( good job and let me know about it.
Strongly Disagree
150. During the past 7 days, on how many days )
( count soda or pop, sports drinks, energy )
NO!! no yes YES!! drinks, or 100% fruit juice.) were you physically active for a total of at
( How much do you do the following when you least 60 minutes per day? Add up all the time you )
( have a problem of any kind? I did not drink sugar-sweetened beverages during
spend in any kind of physical activity that increases your )
( How important is each of the following to you the past 7 days
heart rate and makes you breathe hard some of the time. )
( in your life? 39. I try to find different solutions to the 1 to 3 times during the past 7 days )
( 4 to 6 times during the past 7 days 0 days 3 days 6 days )
problem. 1 day 4 days 7 days
( 34. … Accepting responsibility for my actions 1 time per day )
( A lot 2 times per day 2 days 5 days )
when I make a mistake or get in trouble.
( Sometimes 3 times per day )
( Extremely Important A little 4 or more times per day )
Quite Important 151. On an average school night, how many
( Never )
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Not Sure hours of sleep do you get?
( )
( Somewhat Important 145. ...did you drink a can, bottle, or glass of an 4 or less hours 8 hours )
( Not Important energy drink, such as Red Bull or Jolt? (Do 5 hours 9 hours )
( not count diet energy drinks or sports drinks 6 hours 10 or more hours )
( such as Gatorade or PowerAde.) 7 hours )
( I did not drink energy drinks during the past 7 days )
( 1 to 3 times during the past 7 days )
( 4 to 6 times during the past 7 days )
( 1 time per day )
( 2 times per day )
( 3 times per day )
( 4 or more times per day )
( )
( ] ]] ] ] 4
] ] ] 13
] ]] ] )
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( )
( Think about the people who know you well. How The next section asks about your experiences related )
( do you think they would rate you on each of these? 17. My teacher notices when I am doing a good How many times have you: )
to civic engagement. job and lets me know about it.
( 24. …participated in school or non-school- )
( During the last 12 months, how many times @@@@
NO!! @@@@
no @@@@
yes YES!!
based activities after the regular school day )
( People who know me would say this: have you: @@@@
ended @@@@
(e.g., sports, clubs,@@@@
art or music )
( groups, student government, scouting, etc.)? )
( 152. Giving up when things get hard for me is … 18. I feel safe at my school. )
157. …been a leader in a group or organization?
( Not at all like me @@@@
NO!! @@@@
no @@@@
yes YES!! Never )
( A little like me Never 3-4 times I’ve done it, but not in the past year )
( Somewhat like me Once 5 or more times Less than once a month )
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( Quite like me Twice 19. There are lots of chances for students at my About once a month )
( Very much like me school to talk with a teacher one-on-one. Two or three times a month )
( 158. …helped make sure that all people are @@@@
NO!! @@@@
no @@@@
yes YES!! Once a week or more )
( )
( 153. Knowing how to say "no" when someone treated fairly?
)
( wants me to do things I know are wrong or Never 3-4 times 20. The school lets my parents know when I 25. …volunteered to do community service? )
( dangerous is … Once 5 or more times have done something well. Never )
( Not at all like me Twice @@@@
NO!! @@@@
no @@@@
yes YES!! I’ve done it, but not in the past year )
( A little like me Less than once a month )
( Somewhat like me
159. …stood up for what you believed, even The next section asks about how you spend your
About once a month )
( Quite like me
when it was unpopular to do so? Two or three times a month )
( Very much like me time after school. Once a week or more )
( Never 3-4 times )
( Once 5 or more times )
( 154. Thinking through the possible good and bad Twice On an average school day, how many hours do you: On an average school day, how many hours do )
( results of different choices before I make you spend: )
( decisions is… The next section asks about sexual harassment and 21. …watch TV? )
( Not at all like me sexual discrimination. Sexual harassment is unwanted Not at all 26. …doing homework outside of school? )
( A little like me and unwelcome sexual behavior that interferes with Less than 1 hour per day None )
( Somewhat like me someone’s life at school or any school sponsored 1 hour per day Half hour or less )
( Quite like me activity (like band, sports, field trips, bus rides, or 2 hours per day Between a half hour and an hour )
( Very much like me school activities/clubs). Sexual harassment includes 3 hours per day 1 hour )
( unwelcome sexual advances, regardless of sexual 4 hours per day 2 hours )
( orientation; requests for sexual favors; spreading 5 or more hours per day 3 hours or more )
( How much do you agree or disagree with the sexual rumors; and other inappropriate verbal, )
( following statements?: electronic, or physical conduct of a sexual nature. 22. …play video or computer games or use a )
( Sexual harassment is NOT behaviors that a person computer for something that is not school 27. …going to work? )
( 155. I get along well with students who are likes or wants or is agreed to between two people (for work? (Count time spent playing games, None )
( different from me. example, kissing, touching, flirting that you both agree Half hour or less )
watching videos, texting, or using social
( Strongly Agree to). Sexual discrimination is a verbal, electronic or media on your smartphone, computer, Xbox, Between a half hour and an hour )
( Agree physical action that denigrates or shows hostility PlayStation, iPad, or other tablet.) 1 hour )
( Not Sure towards an individual because of their sex, sexual
Not at all
2 hours )
( Disagree orientation, or gender identification. Both sexual
Less than 1 hour per day
3 hours or more )
( Strongly Disagree harassment and sexual discrimination may create an
1 hour per day )
( intimidating, hostile, or offensive learning
2 hours per day )
( environment for the victim and/or bystanders. 28. …staying after school to participate in a )
( 156. I know how to disagree without starting an
3 hours per day team, club, program, etc.?
4 hours per day )
( argument or fight. None )
How many times in the past year: 5 or more hours per day
( Strongly Agree Half hour or less )
( Agree
160. …has another student sexually harassed
Between a half hour and an hour )
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( Not Sure 23. Are there sports teams or other after-school 1 hour )
you? activities for people your age available in
( Disagree 2 hours )
( Strongly Disagree Never 10 to 19 times your community? 3 hours or more )
( 1 to 2 times 20 to 29 times @@@@
NO!! @@@@
no @@@@
yes YES!! )
( 3 to 5 times 30 to 39 times )
( 6 to 9 times 40 or more times )
( )
( )
( )
( )
( PLEASE DO NOT WRITE IN THIS AREA PLEASE DO NOT WRITE IN THIS AREA
)
( ] ]] ] 14
] ] ] 3
] ] ]] ] )
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( )
( These questions ask for some )
( general information about the people 9. What language do you use most often at 161. …have you sexually harassed another student? 166. My school takes complaints of sexual )
( home? Never 10 to 19 times discrimination and sexual harassment )
completing the survey. seriously and responds effectively to the
( Amharic Korean 1 to 2 times 20 to 29 times )
( Arabic Spanish complaints it receives. )
3 to 5 times 30 to 39 times
( Please mark the response that best Chinese Urdu 6 to 9 times 40 or more times Strongly Agree )
( describes you. English Vietnamese Agree )
( Farsi Other Neutral )
( 1. How old are you? 162. …were you aware of sexual rumors being Disagree )
( 10. Has your parent or guardian ever served in spread at school or at a school-sponsored Strongly Disagree )
10 13 16 19 or older
( 11 14 17
the military (Army, Navy, Air Force, Marines, activity, either verbally or through electronic )
( 12 15 18
Coast Guard, Space Force, National Guard, means such as texting or social media? )
( and Reserves)? Never 10 to 19 times 167. During the past year, I have witnessed an )
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( 2. What grade are you in? Yes No Not Sure 1 to 2 times 20 to 29 times act of sexual discrimination or sexual )
( 3 to 5 times 30 to 39 times
harassment against a student by a student, )
( 8th 10th 12th 11. Do you have someone in your family (like a )
faculty member, or a third party.
( parent, brother, sister) who is currently in the 6 to 9 times 40 or more times
)
( 3. Are you: military (Army, Navy, Air Force, Marines, Yes No
)
( Female Male Coast Guard, Space Force, National Guard, 163. If I observed or was a victim of sexual )
( and Reserves)? discrimination, including sexual harassment 168. During the past year, I reported an act of )
( 4. Some people describe themselves as Yes No Not Sure or sexual violence, I would know who to sexual discrimination or sexual harassment )
( transgender when their sex at birth does not report that information to. to school personnel. )
( match the way they think or feel about their
Yes No
)
( gender. Are you transgender? The next section asks about your experiences at Strongly Agree )
( No, I am not transgender school. Agree )
( Yes, I am transgender Neutral )
( I am not sure if I am transgender
12. Putting them all together, what were your
Disagree
The next section asks about your perceptions of respect )
( I do not know what this question is asking
grades like last year?
Strongly Disagree at your school. )
( )
( 5. Which of the following best describes you?
Mostly Fs Mostly Bs )
( Mostly Ds Mostly As 164. I would feel comfortable reporting sexual How strongly do you agree or disagree with the )
( Heterosexual (straight) Mostly Cs discrimination or sexual harassment or following statements about this school? Most )
( Gay or lesbian assault to school faculty or staff. teachers and other adults at this school… )
Bisexual 13. During the last four weeks, how many days
( of school have you missed because you Strongly Agree )
Not sure
( skipped or "cut"? Agree 169. …care about students. )
( 6. What do you consider yourself to be? Neutral Strongly Agree
)
( Select ONE only.
None 4-5 days
Disagree Agree
)
( 1 day 6-10 days
Strongly Disagree Disagree
)
Hispanic or Latino
( 2 days 11 or more days
Strongly Disagree
)
( Not Hispanic nor Latino 3 days )
(
7. What do you consider yourself to be? 14. I think sometimes it is okay to cheat at school. 165. If you would not feel comfortable reporting )
( an act of sexual discrimination or sexual 170. …want students to do well. )
Select ONE OR MORE.
( NO!! no yes YES!! harassment to school faculty or staff, please )
( American Indian or Alaskan native
How much do you agree or disagree with the indicate why: (Choose ALL that apply) Strongly Agree )
( Asian
following? I would be more comfortable handling the
Agree )
( Black or African-American
situation myself
Disagree )
( Native Hawaiian or other Pacific Islander
15. I can do well in school if I want to.
Strongly Disagree )
I do not know a trusted adult to tell
( )
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( Strongly Agree Disagree I would be afraid of retaliation or continued )
8. Think of where you live most of the time. harassment 171. …listen to what students have to say.
( Which of the following people live there
Agree Strongly Disagree )
( with you?Choose ALL that apply.
Not Sure I would be too embarrassed to talk about it to an Strongly Agree )
( 16. Do you agree or disagree that harassment
adult Agree )
( Mother Other adults
and bullying by other students is a problem
I would be afraid people would think it was my Disagree )
( Father Sister(s)
at your school?
fault Strongly Disagree )
( Stepmother Brother(s) I would be afraid I would get in trouble )
( Stepfather Stepsister(s) Strongly Agree Disagree I do not think my report would be taken seriously )
( Grandmother(s) Stepbrother(s) Agree Strongly Disagree and nothing would be done )
( Grandfather(s) Other children Not Sure )
( Foster parent )
( )
( )
( ] ]] ] ] 2
] ] ] 15
] ]] ] )
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( )
( 172. …treat students with respect. 2021 FAIRFAX COUNTY )
( Youth Survey of 8th, 10th, and 12th Grade Students )
( Strongly Agree )
( Agree Thank you for agreeing to participate in this study. These questions ask your opinion about a )
( Disagree )
( Strongly Disagree number of things concerning you, your friends, your family, your neighborhood, and your )
( community. )
( )
( 173. How honest were you in filling out this )
( survey? DO NOT write your name on this survey. Your individual answers to the survey are anonymous, )
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( I was very honest which means that no one will know how you answered. Student answers will be summarized in a )
( I was honest pretty much of the time report that will not include anyone’s name. This survey is completely voluntary. You can skip any )
( I was honest some of the time )
( I was honest once in a while questions that you do not want to answer. )
( I was not honest at all )
( Be sure to read the instructions below before you begin. Thank you very much. )
( )
( This is the end of the survey. )
( Thank you for participating. )
( INSTRUCTIONS )
( )
( 1. This is not a test, so there are no right or wrong answers. )
( )
( )
( 2. All of the questions should be answered by marking one of the answer spaces unless otherwise )
( noted. If you do not find an answer that fits exactly, use the one that comes closest. If any )
( )
( question does not apply to you, or you are not sure what it means, just leave it blank. )
( )
( 3. For questions that have the following answers: NO!! no yes YES!! )
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( Mark the big YES!! if you think the statement is DEFINITELY TRUE for you. )
( Mark the little yes if you think the statement is MOSTLY TRUE for you. )
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( Mark the little no if you think the statement is MOSTLY NOT TRUE for you. )
( Mark the big NO!! if you think the statement is DEFINITELY NOT TRUE for you. )
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( Example: Chocolate is the best ice cream flavor. )
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( @@@
NO!! @@@
no @@@!@@
yes YES!! )
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( 4. Your answers will be read automatically by a scanner and computer. Please follow these )
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( instructions carefully. )
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( MARKING INSTRUCTIONS )
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( a. Use a No. 2 pencil or a blue or black pen only.
This kind of mark will work: )
aab
baa

aab
baa
( Correct Mark )
( b. Do not use pens with ink that soaks through the paper. )
( @ @!@ @ )
( c. Make solid marks that fill the response completely. These kinds of marks will NOT work: )
( Incorrect Marks )
( d. Make no stray marks on this form.
v@ y@w @ x@ )
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( PLEASE DO NOT WRITE IN THIS AREA PLEASE DO NOT WRITE IN THIS AREA
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baa
aab aab
baa