HEalth Behavior and School Experiences Survey

Student Survey DO NOT WRITE YOUR NAME ANYWHERE ON THIS SURVEY

OMB #: 1850-0818

Expiration Date: MM/DD/YY

Health Behavior and School Experiences Survey

This survey asks for information about your participation in school activities
and your health knowledge, attitudes, and behaviors.
Please answer all of the questions honestly.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx (expiration date: xx/xx/xx). The time required to complete this information collection is estimated to average 1/2 hour, including the time to review instructions, search existing data resources, gather the data needed, and complete the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please contact Paul Strasberg, U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue NW, Washington, DC 20208, paul.strasberg@ed.gov. If you have comments or concerns regarding the status of your individual submission of this form, e-mail directly to XXXXX.@XXXX

Personally identifiable information in this questionnaire will not be released to anyone or any organization, except as required by law.

Health Behavior and School Experiences Survey

Thank you for taking the time to complete this survey. This survey is very important because it will help the U.S. Department of Education and schools understand student participation in school activities and attitudes toward school and substance use. The survey has questions about your school, your family, and your attitudes and experiences with alcohol and other drugs.

Your answers to all of the questions are will be kept confidential. Neither school staff, your parents, nor anyone else outside the study team will see your answers to any questions on this form. This survey is completely voluntary. You may skip any question and you may stop at any time. There will be no negative consequences related to your answers on this survey. Some of the questions are personal and some students may find them upsetting. You will be given a list of numbers to call if you want to talk to someone about the survey or feelings it brings up. Please read the instructions below before starting.

Instructions—Please Follow Carefully

Please Answer the Questions Honestly and Return Your Completed Survey
to the Researcher Who Gave it to You.

• DO NOT WRITE YOUR NAME ANYWHERE ON THIS SURVEY.

• Use only a blue (preferred) or black pen.

• Mark only one circle for each question, unless the question says otherwise.

• M ake your marks dark, like this: 

Incorrect way to fill in circles: O

• If you fill in the wrong circle, go ahead and fill in the corrected (right) answer, and circle it.

Example: Yes:● No:●

(In this example, “no” is the correct answer; the student accidentally filled out the “yes” circle).

• If you have a question about the survey as you are filling it out, please ask the researcher who is administering the survey.

Section 1: This section asks about you and your participation in school activities.

12 or younger

13

14

15

16

17

18

19 or older

1. How old are you?

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Male

Female

2. Are you male or female?

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9

10

11

12

3. What grade are you in?

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4. Are you Hispanic or Latino? Yes, I am Hispanic or Latino  No, I am not Hispanic or Latino 

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

5. Which of the following groups best describes you? Select one or more.

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English

Spanish

An Asian language

Other

6. What language is usually spoken in your home?

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Some high school credits

Complete high school

Some college credits

A college degree

Graduate or professional school after college

7. What is the highest level of schooling you think you will reach?

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Mostly As

Mostly Bs

Mostly Cs

Mostly Ds

Mostly Fs

8. Which category best describes your grades last year?

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9. Some school sports are listed below. For each activity, mark the answer that describes your participation. Remember, this question is only about school sports. Mark all the circles that apply to you.
			I participated last school year (2005–2006)	I have participated, am participating, or will participate this school year (2006–2007)		I plan to participate next school year (2007–2008)
a. Football						
b. Volleyball						
c. Cross country						
d. Soccer						
e. Basketball						
f. Wrestling						
g. Swimming or diving						
h. Track and field						
i. Tennis						
j. Golf						
k. Softball						
l. Baseball						
m. Gymnastics						
n. Weightlifting						
o. Field hockey						
p. Lacrosse						
q. Rowing						
r. Squash						
s. Other (write the name of any school sports you participate in that are not listed above).
i) _________________						
ii) _________________						
iii) _________________						

If you did not participate in any school sports last year (2005–5006), mark this circle. 

If you are not participating in any school sports any time this year (2006–2007), mark this circle. 

If you do not plan to participate in any school sports next year (2007–2008), mark this circle. 

10. Listed below are some other school activities that are not sports. For each activity, mark the answer that describes your participation. Remember, this question is only about school activities. Mark all the circles that apply to you.
	I participated last school year (2005–2006)	I have participated, am participating, or will participate this school year (2006–2007)	I plan to participate next school year (2007–2008)
a. Drama			
b. Band			
c. Choir			
d. Cheerleading or rally			
e. Dance			
f. Drill			
g. Academic clubs (math team, debate, science bowl)			
h. Student Council/Government (class officer, peer counselor, task force member)			
i. Yearbook/Newspaper			
j. Vocational club			
k. Other clubs (Future Farmers of America, Future Business Leaders of America) or activities (write the names of the clubs or activities below)
i) ____________________			
ii) ___________________			

If you did not participate in any non-sport school activities last year (2005–5006), mark this circle. 

If you are not participating in any non-sport school activities any time this year (2006–2007), mark this circle. 

If you do not plan to participate in any non-sport school activities next year (2007–2008), mark this circle. 

Section 2: This section asks about your school and how you feel about it.

11. Please indicate whether you agree with the following statements about you and your school.

		Strongly Agree	Agree	Disagree	Strongly Disagree
a. When students have an emergency someone is there to help.					
b. I feel like I belong at this school.					
c. The principal at this school asks students about their ideas.					
d. We do not waste time in my classes.					
e. I can be myself at this school.					
f. Adults at this school listen to student concerns.					
g. Adults at this school act on student concerns.					
h. It pays to follow the rules at my school.					
i. I have many opportunities to make decisions at my school.					
j. Students of all racial and ethnic groups are respected at my school.					
k. I can be a success at this school.					
l. I can reach my goals through this school.					
m. The rules at my school are fair.					
n. I have friends at this school.					
o. I am comfortable talking with adults at this school about problems.					
p. My schoolwork helps with things that I do outside of school.					
q. I like being at this school.					
r. I feel safe at this school.					

Section 3: This section asks about your use of and attitudes toward different types of drugs. Remember, your answers are confidential. Mark only one circle per row.

		Number of Occasions
12. On how many occasions (if any) have you...		0	1–2	3–5	6–9	10–19	20–39	40 or more
a. smoked cigarettes?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
b. used chewing tobacco, snuff, or dip?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
c. had a glass, can, or bottle of alcohol to drink (beer, wine, wine coolers, hard liquor)?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
d. used marijuana (grass, pot) or hashish (hash, hash oil)?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
e. used cocaine in any form (crack, rock, or powder)?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
f. used steroids or other muscle-building drugs (muscle builders, androstenedione [andro], human growth hormone) illegally without a doctor’s prescription?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
g. sniffed glue, breathed the contents of aerosol spray cans, or inhaled any other gases or sprays to get high?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
h. used narcotic drugs such as heroin, methadone, opium, codeine, or Demerol without a doctor’s prescription?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
i. used amphetamines, methamphetamines, or Ritalin without a prescription? (Also called uppers, ups, speed, bennies, dexies, ice, meth, or pep pills. These drugs are sometimes taken to help lose weight or to increase energy.)	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
j. used any other illegal drug?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
k. been offered drugs or alcohol outside of school?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
l. been offered drugs or alcohol at school?	In your lifetime?							
	In the last 30 days?							
	In your lifetime?							

13. Think back to September 2006. During that month, how many times (if any) did you...
		0	1 or 2	3–5	6–9	10–19	20–39	40 or more
a. smoke cigarettes?								
b. use chewing tobacco, snuff, or dip?								
c. have a glass, can, or bottle of alcohol to drink (beer, wine, wine coolers, hard liquor)?								
d. use marijuana (grass, pot) or hashish (hash, hash oil)?								
e. not counting alcohol, tobacco, or marijuana, use another illegal drug?								

14. Do you think you will use any of the substances listed below within the next year?

		Definitely Not	Probably Not	Maybe	Probably Will	Definitely Will
a. cigarettes?						
b. chewing tobacco, snuff, or dip?						
c. alcohol (beer, wine, wine coolers, hard liquor)?						
d. marijuana (grass, pot) or hashish (hash, hash oil)?						
e. an illegal drug other than alcohol, tobacco, or marijuana?						

		Number of Occasions
15. On how many occasions (if any) have you...		0	1–2	3–5	6–9	10–19	20–39	40 or more
a. been in a physical fight at school?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
b. been in a physical fight outside of school?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							
c. carried a weapon such as a gun, knife, or club on school property?	In your lifetime?							
	In the last 6 months?							
	In the last 30 days?							

16. Please indicate whether you agree or disagree with each statement.

	Strongly Disagree	Disagree	Don’t Agree or Disagree	Agree	Strongly Agree
a. Using illegal drugs leads to serious health problems.					
b. Drinking alcohol leads to serious health problems.					
c. If I used illegal drugs, I would get into trouble.					
d. If I drank, I would get into trouble.					
e. Using illegal drugs or alcohol makes it easier to be part of a group.					
f. Using illegal drugs or drinking is cool.					
g. Using illegal drugs or drinking makes everything seem better.					
h. Using illegal drugs or drinking makes it easier to have a good time with friends.					
i. If I were to be drug tested, I would try to beat the drug test.					
j. Drug testing is helpful to keep students healthy and off drugs.					
k. I have close friends who use illegal drugs.					
l. My friends would disapprove if I drank alcohol.					
m. My friends would disapprove if I used illegal drugs.					

Section 4: This section asks about activities at your school.

17. Please indicate whether the following statements are true or false.

	True	False	Don’t Know
a. My school offers mentoring services.			
b. In the past 6 months I or someone I know participated in activities with a mentor.			
c. My school has clearly defined rules about alcohol, drugs, fighting, and weapon carrying.			
d. In the past 6 months I or someone I know got in trouble for violating my school’s rules about alcohol, drugs, fighting, or weapon carrying.			
e. At my school students who participate in some sports or other activities may be randomly tested for drugs.			
f. My school plans to test students for drugs in the near future.			
g. In the past 6 months I could have been tested for drugs by my school.			
h. In the past 6 months I or someone I know was tested for drugs by my school.			
i. My school offers after-school or evening activities for students.			
j. In the past 6 months I or someone I know participated in my school’s after-school or evening activities for students.			
k. My school has organizations that promote substance use prevention.			
l. In the past 6 months I or someone I know participated in my school’s organizations that promote substance use prevention.			

18. How honest were you in filling out this survey?

 I was very honest.

 I was honest pretty much of the time.

 I was honest some of the time.

 I was honest once in a while.

 I was not honest at all.

Thank you! You have completed the survey. Please check to make sure your name
does not appear on any page then place it in the envelope provided and turn it in.

If you need to talk to someone . . .

If the survey upset you for any reason, or if you just want to talk about a problem you or someone else about is having with alcohol or drugs, we suggest you do one of these things right away:

• Talk to an adult you trust in your family or community, such as your parents or religious leader.

• Talk to an adult you trust at school, such as a teacher, counselor, nurse, intervention specialist, or principal.

• Call one or more of the places listed below.

Name	Number	Spanish Speaking	Confidential	Cost
CSAT Alcohol/Drug Referral Line (National 24-hour Help Line)	(800) 662-4357	Yes	Yes	None
Care Crisis Response Services	(800) 584-3578	Tele-Interpreter Available	Yes	None
Girls’ and Boys’ Town (alcohol and other drugs) 24-Hour Hotline	(800) 448-3000	Yes	Yes	None

For questions about the survey: Eric Einspruch or Chandra Lewis, RMC Research Corporation, 800-788-1887.

For questions about your rights as a study participant: Human Subjects Research Review Committee in the Office of Research and Sponsored Projects, 111 Cramer Hall, Portland State University 503-725-4288.

School ID, Student ID
February 2007