1.

YOUTH RISK BEHAVIOR SURVEY - GATES INTERMEDIATE SCHOOL

This survey for middle school students is about health behavior. It has been developed so you can
tell us what you do that may affect your health. The information you give will be used to improve
health education for young people like yourself.
This survey is anonymous and the answers you give will be kept private. No one will know what
you write. Please be truthful and answer the questions based on what you really do.
Completing the survey is voluntary. Whether or not you answer the questions will not affect your
grade in this class. If you are not comfortable answering a question, just leave it blank.
The questions that ask about your background will be used only to describe the types of students
completing this survey. The information will not be used to find out your name. Again, no names
will ever be reported.
Make sure to read every question and select the most appropriate answer.
Thank you very much for your help!
* 1. What is your gender/sex?
Female
Male

* 2. In what grade are you?

7th grade
8th grade

* 3. How old are you?

12 years old or younger
13 years old
14 years old
15 years old

* 4. What is your race? (Select one or more responses.)

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White

5. During the past 12 months, how would you describe your grades in school?
Mostly A's
Mostly B's
Mostly C's
Mostly D's
Mostly F's

6. Are you elgible to receive free or reduced price lunches at your school?
Yes
No
Don't know/Not sure

2. BULLYING

The next 4 questions ask about bullying. Bullying is when 1 or more students repeatedly harm,
harass, intimidate or exclude others. Bullying is unfair and one sided. It is not bullying when 2
students of about the same strength or power argue or fight or tease each other in a friendly way.
1. During the past 12 months, have you ever been bullied on school property?
Yes
No

2. During the past 12 months, have you ever been electronically bullied? (Include being bullied through email, social media, texting, etc.)
Yes
No

3. During the past 30 days, on how many days did you not go to school because you felt you would be
unsafe at school or on your way to or from school as a result of a threat made by another student?
0 days
1 day
2 or 3 days
4 or 5 days
6 or more days

4. During the past 12 months have you ever done any of the following (click all answers that apply)?
Bully or push someone around
Use texting, e-mail, or social networking sites to make fun of threaten, or insult another kid, or try to hurt another kids's reputation
Threaten to hurt, physically hurt, or try to hurt a date or someone you were going out with
I have never bullied another student

3. SAD OR SUICIDAL FEELINGS

The next 6 questions ask about sad feelings and attempted suicide. Sometimes people feel so
depressed about the future that they may consider attempting suicide, that is, taking some action
to end their own life.
Why do we ask?
Prevalence of Child and Adolescent Mental Disorders
Four million children and adolescents in this country suffer from a serious mental disorder that
causes significant functional impairments at home, at school and with peers. Of children ages 9 to
17, 21 percent have a diagnosable mental or addictive disorder that causes at least minimal
impairment.
Half of all lifetime cases of mental disorders begin by age 14. Despite effective treatments, there are
long delays, sometimes decades, between the first onset of symptoms and when people seek and
receive treatment. An untreated mental disorder can lead to a more severe, more difficult to treat
illness and to the development of co-occurring mental illnesses.
In any given year, only 20 percent of children with mental disorders are identified and receive
mental health services.
Consequences of Untreated Mental Disorders in Children and Adolescents
Suicide
Suicide is the third leading cause of death in youth ages 15 to 24. More teenagers and young adults
die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza
and chronic lung disease combined.5 Over 90 percent of children and adolescents who commit
suicide have a mental disorder.
In the United States in the year 2002, almost 4,300 young people ages 10 to 24 died by suicide.
School Failure
Approximately 50% of students age 14 and older who are living with a mental illness drop out of
high school. This is the highest dropout rate of any disability group.
How results impact instruction?
Data is used to exam at risk behaviors and helps to drive student interventions and health
curriculum.

1. During the past 12 months, did you ever feel so sad or hopeless almost everyday for two or more weeks
in a row that you stopped doing usual activities?
Yes
No

2. During the past 12 months, did you ever seriously consider attempting suicide?
Yes
No

3. During the past 12 months, did you make a plan about how you would attempt suicide?
Yes
No

4. Have you ever tried to kill yourself?

Yes
No

5. If you attempted suicide, did any attempt result in any injury, poisoning, or overdose that had to be
treated by a doctor or nurse?
I have never attempted suicide
Yes
No

6. Have you ever purposely injured yourself by using a sharp object to scratch or cut your skin deep
enough to draw blood?
Yes
No

4. FAMILY AND PEERS

The next 23 questions are about your family and peers.

Why do we ask?
These questions are designed to address students perception about attitudes related to drug and
alcohol use.
How data impacts instruction?
Understanding how students perceive the dangers of a drug allows us to better address
instructional strategies in the health classroom.
Data is used in delivery of health curriculum to help students realize that most of their peers have
negative attitudes about using drugs and alcohol and that they are in the majority by making
healthy decisions.
1. 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? *
No risk
Slight risk
Moderate risk
Great risk

2. How wrong do your parents feel it would be for you to smoke tobacco? *
Not at all wrong
A little bit wrong
Wrong
Very wrong

3. How wrong do your friends feel it would be for you to smoke tobacco? *
Not at all wrong
A little bit wrong
Wrong
Very wrong

4. Here are some things kids your age have said about drinking alcohol. How strongly do you agree or
disagree with each statement? (select one box for each item)
Strongly disagree

Disagree a little

Agree a little

Strongly agree

Relaxes you
Makes you do poorly in
sports
Let's you have more fun
Gets you into trouble
Helps you get away from
your problems
Slows down your
reaction time
Would disappoint my
friends
Could get me into
embarrassing situations

5. Which statement below about drinking alcholic beverages do you feel best represents your own attitude?
Drinking is never a good thing to do for anyone at any age.
Drinking in moderation is all right for adults, but not for students my age except for just a few sips in a family or religious gathering.
Occasional drinking at my age beyond just a few sips in a family or religious gathering is okay as long as it doesn't interfere with
school work or other responsibilities.
Occasional drinking at my age is okay even it does interfere with school work or other responsibilities.
Frequent drinking at my age is okay if that's what the individual wants to do.

6. Which statement below about drinking alcholic beverages do you expect to be the most common attitude
among students in general in your grade?
Drinking is never a good thing to do for anyone at any age.
Drinking in moderation is all right for adults, but not for students my age except for just a few sips in a family or religious gathering.
Occasional drinking at my age beyond just a few sips in a family or religious gathering is okay as long as it doesn't interfere with
school work or other responsibilities.
Occasional drinking at my age is okay even it does interfere with school work or other responsibilities.
Frequent drinking at my age is okay if that's what the individual wants to do.

7. How much do you think people risk harming themselves physically or in other ways when they have five
or more drinks of an alcoholic beverage once or twice a week? *
No risk
Slight risk
Moderate risk
Great risk

8. 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 nearly every day? *
No risk
Slight risk
Moderate risk
Great risk

9. How wrong do your parents feel it would be for you to have one or two drinks of an alcoholic beverage
nearly every day? *
Not at all wrong
A little bit wrong
Wrong
Very wrong

10. How wrong do your friends feel it would be for you to have one or two drinks of an alcoholic beverage
nearly every day? *
Not at all wrong
A little bit wrong
Wrong
Very wrong

11. How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly
every day? *
Neither Approve or Disapprove
Somewhat Disapprove
Strongly Disapprove
Don't know or can't say

12. How much do you think people risk harming themselves physically or in other ways if they smoke
marijuana once or twice per week? *
No risk
Slight risk
Moderate risk
Great risk

13. How wrong do your parents feel it would be for you to smoke marijuana? *
Not at all wrong
A little bit wrong
Wrong
Very wrong

14. How wrong do your friends feel it would be for you to smoke marijuana? *
Not at all wrong
A little bit wrong
Wrong
Very wrong

15. How much do you think people risk harming themselves physically or in other ways if they use
prescription drugs that are not prescribed to them? *
No risk
Slight risk
Moderate risk
Great risk

16. How wrong do your parents feel it would be for you to use prescription drugs not prescribed to you? *
Not at all wrong
A little bit wrong
Wrong
Very wrong

17. How wrong do your friends feel it would be for you to use prescription drugs not prescribed to you? *
Not at all wrong
A little bit wrong
Wrong
Very wrong

18. Do you think most people your age do the following?

Yes

No

Drink Alcohol
Smoke cigarettes
Smoke marijuana
Use other illegal drugs
Bully, threaten, or push
around other kids

19. During the past 30 days, on how many days do you think the following individuals had at least one
drink of alcohol?
0 days

1 or 2 days

3 to 5 days

6 to 9 days

10 or more days

Students in your grade

Males in your grade
Females in your grade

20. What limits, if any, would you say are most typical of other students' parents concerning student
drinking in the home?
No drinking is allowed (other than a few sips in a family or religious gathering)
Some drinking is allowed with a parent when only family members are present
Some drinking with friends is allowed if a parent is present
Drinking is allowed without a parent present as long as the student does not get drunk or drive afterwards
No limits

21. During the past thirty days, have you and your parent(s) discussed underage drinking?
Yes
No

22. During the past thirty days, have you and your parent(s) discussed rules and expectations about
drinking?
Yes
No

23. How much do you think people risk harming themselves physically or in other ways if they use once or
twice a week:
No Risk
Steroids (body building
hormone)
Adderall or Ritalin (from
a prescription that is not
your own)
Oxycontin, Percocet or
Vicodin (from a
prescription that is not
your own)
Inhalants (sniffing glue,
breathing the contents of
aerosol spray cans, or
inhaling any paints or
spray to get high)
Heroin

Slight Risk

Moderate Risk

Great Risk

5. TOBACCO USE - SMOKING & SMOKELESS TOBACCO

The next 10 questions ask about tobacco use.

Why do we ask?
These questions are designed to determine the percentage of students that self-report use of
nicotine products.
Teens that smoke cigarettes are 14 times more likely to use marijuana.
Most smokers start during their teen year and teens are the most likely to become addicted.
If a person doesnt start smoking before the age of 19, it is unlikely they will ever start.
How data impacts instruction?
Understanding use of nicotine helps us to create additional interventions related to smoking.
Based on data from last year, it is easy to make statements like 99% of Gates students last year
were not current users of cigarettes. This demonstrates that healthy decision making around
smoking is the norm for middle school students and not smoking in middle school makes you part
of the strong majority that makes healthy decisions.
1. Have you ever tried cigarette smoking, even one or two puffs?
Yes
No

2. How old were you when you smoked a whole cigarette for the first time?
I have never smoked a whole cigarette
8 years old or younger
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old or older

3. During the past 30 days, how many days did you smoke part or all of a cigarette? *
0 days
1 or 2 days
3 to 9 days
10 or more days

4. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
I did not smoke cigarettes during the past 30 days
Less than 1 cigarette per day
1 cigarette per day
2 to 5 cigarettes per day
6 to 10 ciagarettes per day
11 to 20 cigarettes per day
More than 20 cigarettes per day

5. During the past 30 days, how did you usually get your own cigarettes? (Select only one response)
I did not smoke cigarettes during the past 30 days
I bought them in a store such as a convenience store, supermarket, discount store, or gas station
I bought them from a vending machine
I gave someone else money to buy them for me
I borrowed(bummed)them from someone else
A person 18 years old or older gave them to me
I took them from a store or a family member
I got them some other way

6. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?
Yes
No

7. During the past 30 days, how many days did you use chewing tobacco, snuff, or dip?
0 days
1 or 2 days
3 to 9 days
10 or more days

8. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
0 days
1 or 2 days
3 to 9 days
10 or more days

9. In your opinion, what percentage of middle school students use tobacco products (cigarettes, cigars, dip,
chewing tobacco, ect.)?
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
91-100%

10. In your opinion, what percentage of high school students use tobacco products (cigarettes, cigars, dip,
chewing tobacco, ect.)?
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
91-100%

6. TOBACCO USE - VAPORIZER - HOOKAH USE

The next series of questions ask about vaporizer and hookah use.
1. Have you ever tried vaping (vape pen, e-cigarette, etc.)?
Yes
No

2. During the past 30 days, how many days did you vape?
0 days
1 or 2 days
3 to 9 days
10 or more days

3. During the past 30 days, which substance did you mostly use in the vaping device?
I did not vape during the past 30 days.
Molasses Tobacco
Marijuana
Nicotine Tobacco
Flavoring
Other (please specify)

4. Have you ever used a hookah?

Yes
No

5. During the past 30 days, how many days did you use a hookah?
0 days
1 or 2 days
3 to 9 days
10 or more days

6. During the past 30 days, which substance did you mostly use in the hookah?
I did not use a hookah during the past 30 days.
Molasses Tobacco
Marijuana
Nicotine Tobacco
Flavoring
Other (please specify)

7. ALCOHOL USE

The next 8 questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers,
and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not
include drinking a few sips of wine for religious purposes.
Why do we ask?
These questions are designed to determine the percentage of students that self-report use of
alcohol.
5,000 young people under the age of 21 die as a result of underage drinking every year.
People who reported starting to drink before the age of 15 were four times more likely to also
report meeting the criteria for alcohol addiction compared to those that waited until they were at
least 20 years of age.
More than 67 percent of young people who start drinking before the age of 15 will try an illegal
drug.
Alcohol use is also a strong predictor of other risk factors.
How data impacts instruction?
Understanding use of alcohol helps us to create additional interventions related to alcohol.
Based on data from last year, it is easy to make statements like 97% of Gates students last year are
not current users of alcohol. This demonstrates that healthy decision making around alcohol use
is the norm for middle school students at Gates. Gates students would be in a small minority by
using alcohol.
1. Have you ever had a drink of alcohol other than a few sips?
Yes
No

2. How old were you when you had your first drink of alcohol other than a few sips?
I have never had a drink of alcohol other than a few sips
8 years old or younger
9 years old
1o years old
11 years old
12 years old
13 years old
14 years old
15 years old or older

3. During the past 30 days, how many days did you drink one or more drinks of an alcoholic beverage? *
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 or more days

4. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is,
within a couple of hours?
0 days
1 day
2 days
3 to 5 days
6 to 9 days
10 or more days

5. During the past 30 days, how did you usually get the alcohol you drank?
I did not drink alcohol during the past 30 days
I gave someone else money to buy it for me
I took it from a store or family member
I got it some other way

6. Have you ever gone to a party where teens were drinking?

Yes
No

7. Have you ever been to party where teens were drinking and the parent's/guardian's were home and
aware of the drinking?
Yes
No

8. If you have attended a party where teens were drinking, did you drink?
I have never been to a party where teens were drinking
Yes
No

9. In your opinion, what percentage of middle school students have had at least one drink of alcohol in the
last 30 days?
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
91-100%

10. In your opinion, what percentage of high school students have had at least one drink of alcohol in the
last 30 days?
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
91-100%

8. MARIJUANA USE

The next 5 questions ask about marijuana use. Marijuana also is called grass or pot.
Why do we ask?
These questions are designed to determine the percentage of students that self-report use of
marijuana.
Teens that use marijuana are 2 times more likely to suffer from depression.
Teenagers 12 to 17 who smoke marijuana weekly are three times more likely to have thoughts of
committing suicide.
Daily use of marijuana among girls is associated with a fivefold increase in the odds of developing
depression and anxiety.
How data impacts instruction?
Understanding use of marijuana helps us to create additional interventions if necessary related to
marijuana use.
Based on data from last year, it is easy to make statements like 97% of Gates students last year are
not current users of marijuana and most students have never tried marijuana. This demonstrates
that healthy decision making around marijuana use is the norm for middle school students at
Gates. Gates students would be in a small minority by using marijuana.
1. During your life, on how many days have you used marijuana?
I have never tried marijuana
1 or 2 days
3 to 9 days
10 or more days

2. How old were you when you tried marijuana for the first time?
I have never tried marijuana
8 years old or younger
9 or 10 years old
11 or 12 years old
13 or 14 years old
15 years old or older

3. During the past 30 days, how many times have you used marijuana or hashish? *
0 times
1 or 2 times
3 to 9 times
10 or more times

4. In your opinion, what percentage of middle school students have used marijuana in the last 30 days?
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
91-100%

5. In your opinion, what percentage of high school students have used marijuana in the last 30 days?
0-10%
11-20%
21-30%
31-40%
41-50%
51-60%
61-70%
71-80%
81-90%
91-100%

9. OTHER DRUG USE

The next 3 questions ask about other drugs.

Why do we ask?
These questions are designed to determine the percentage of students that self-report use of other
drugs.
How data impacts instruction?
Understanding use of other drugs helps us to create additional interventions if necessary related to
other drug use.
Based on data from last year, it is easy to make statements like 99% of Gates students last year had
never used prescription drugs not prescribed for them or in a way that they were not prescribed.
This demonstrates that healthy decision making around prescription use is the norm for middle
school students at Gates. Gates students would be in a small minority by using prescription drugs
that were not prescribed for them or in a way they were designed to be used.
1. During your life, how many times have you sniffed glue, breathed the contents of aersol spray cans, or
inhaled any paints or sprays to get high?
0 times
1 or 2 times
3 to 9 times
10 or more times

2. During the past 30 days, how many times have you used prescription drugs not prescribed to you? *
0 times
1 or 2 times
3 to 9 times
10 or more times

3. During the past 12 months, has anyone offered, sold, or given you an illegal drug or drug not prescribed
for you on school property?
Yes
No

10. SEXUAL BEHAVIOR

The next 4 questions ask about sexual behavior.

Why do we ask?
These questions are designed to determine the percentage of students that self-report that they are
sexually active.
More than 1 in 4 teens who gave birth were between the ages of 15 and 17.
Pregnancy and birth are significant contributors to high school drop out rates among girls
The children of teenage mothers are more likely to have lower school achievement and drop out of
high school, have more health problems, be incarcerated at some time during adolescence, give
birth as a teenager, and face unemployment as a young adult.
How data impacts instruction?
Understanding the number of students that are sexually active helps us to create additional
interventions if necessary related to sexual activity and other high risk behaviors.
Based on data from last year, it is easy to make statements like 96% of Gates students last year had
never had sex. This demonstrates that healthy decision making around practicing abstinence is the
norm for middle school students at Gates. Gates students would be in a small minority by being
sexually active during middle school and the pressure is to abstain from sex.
1. Have you ever had sexual intercourse?
Yes
No

2. How old were you when you had sexual intercourse for the first time?
I have never had sexual intercourse
8 years old or younger
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old or older

3. Did you drink alcohol or use drugs before you had sexual intercourse the last time?
I have never had sexual intercourse
Yes
No

4. The last time you had sexual intercourse, did you or your partner use a condom or other form of
protection?
I have never had sexual intercourse
Yes
No

11. BODY WEIGHT

The next 5 questions ask about body weight.

1. How do you describe your weight?
Very underweight
Slightly underweight
About the right weight
Slightly overweight
Very overweight

2. Which of the following are you trying to do about your weight?

Lose weight
Gain weight
Stay the same weight
I am not trying to do anything about my weight

3. During the past 30 days, did you go without eating for 24 hours or more (also called fasting) to lose
weight or to keep from gaining weight?
Yes
No

4. During the past 30 days, did you take any 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.)
Yes
No

5. During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?
Yes
No

12. FOOD & DRINK

The next 5 questions ask about food you ate or drank during 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 sure to include food
you ate at home, at school, at restaurants, or anywhere else.
1. During the past 7 days, how many times did you eat fruit? (Do not count fruit juice.)
I did not eat fruit 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

2. During the past 7 days, how many times did you eat vegetables?
I did not eat vegetables 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

3. During the past 7 days, how many times did you drink a can, bottle, or glass of soda, such as coke,
Pepsi, or Sprite?
I did not drink soda 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. During the past 7 days, how many days did you drink coffee?
I didn't drink any coffee
1 day
2 days
3 days
4 days
5 or more days

5. During the past 7 days, how many days did you drink an energy drink?
I didn't drink any energy drinks
1 day
2 days
3 days
4 days
5 or more days

13. PHYSICAL ACTIVITY

The next 4 questions ask about physical activity.

1. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes
per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and
made you breathe hard some of the time.)
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

2. On an average school day, how many hours do you watch TV?

I do not watch TV on an average school day
Less than 1 hour per day
1 hour per day
2 hours per day
3 hours per day
4 hours per day
5 hours or more per day

3. 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, PlayStation, Nintendo DS, iPod
touch, Facebook, and the Internet.)
I do not play video or computer games or use a computer for something that is not school work
Less than 1 hour per day
1 hour per day
2 hours per day
3 hours per day
4 hours per day
5 hours or more per day

4. During the past 12 months, on how many sports teams did you play? (Count any teams run by your
school or community groups.)
0 days
1 team
2 teams
3 or more teams

14. HEALTH-RELATED TOPICS

The next 5 questions ask about other health-related topics.

1. 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?
Never
Rarely
Sometimes
Most of the time
Always

2. On an average school night, how many hours of sleep do you get?

4 or less hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours

3. During the past 12 months, did you talk to a teacher or other adult in your school about a personal
problem you had?
Yes
No

4. If you answered yes to the above question, please select all answers that apply to reasons you talked to
a teacher or other adult in your school about a personal problem you had?
I answered no to the question above
Conflict with another student
Conflict with a teacher
Conflict with family member
Situation you did not know how to handle on your own
Concern about the well being of another student
Feeling sad
Feeling anxious
Feeling overwhelmed
Other
Other (please specify)

5. If you had a problem would you feel comfortable going to a teacher or another adult in this building?
Yes
No
If you answered "no", why would you not feel comfortable going to a teacher