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pdfAttachment 11 – Community Member, Survey – Youth Instruments
Document E.2: C-KABS Youth
OMB No. XXXX-XXXX
Expiration Date: Month Year
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it displays a currently valid OMB control number. The OMB control number for this project is xxxx-xxxx. Public reporting burden for this
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regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA
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Evaluation of the Native Aspirations Project
Document E.2: Community Knowledge, Awareness, and Behaviors –
Youth Version Ages 11 and older (C-KABS-Y)
You are being asked to participate in this survey because your community, along with other tribal
communities across the country, received federal funding to prevent violence, bullying, and suicide
among Native American youth. As part of the Cross-community Evaluation of the Native Aspirations
Project, we are asking that you complete this Community Knowledge, Awareness, and Behaviors Survey
(C-KABS). This survey includes a series of questions asking you about your experiences, behaviors,
attitudes, and beliefs. The survey also asks about things in your life that both help you grow and create
challenges. The information you give will be used to help Native American youth, Native American
communities, and the Native Aspirations Project.
This is not a test. There are not right or wrong answers to this survey. Please answer the questions
based on what you really think and do. Your honest answers will help us, your community, and other
Indian communities to better understand the needs of young people. DO NOT write your name on this
survey. The answers you give will be anonymous. No one will know what you write. 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.
Completing this survey is voluntary. Whether or not you answer the questions will not affect your grades
in school. If you are not comfortable answering a questions, 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. No names will ever be
reported.
Please read every question and fill in the ovals completely. When you are finished, follow the
instructions of the person giving you the survey.
Contact information: If you have any concerns about your participation in this survey or have any
questions about the evaluation, please contact Christine Walrath at CWalrath@macrointernational.com
(646-695-8154) or Kara Riehman at Kara.S.Riehman@macrointernational.com (404-592-2148). If you
feel upset because of any items on the survey, please see Mr/Mrs NAME who is here today.
Thank you very much for your help.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
C-KABS-Y
Directions:
Use a #2 pencil.
Make dark marks
Fill in a response like this:
Yes
No
If you change your answer, erase your old answer completely
This section asks about your experiences and involvement in school. Please mark the answer
that most closely fits your experience or how you feel.
1. Do you like school?
I like school very much
I like school quite a bit
I like school a bit
I don’t like school very much
I hate school
2. On average, how well do you think you are doing in your school work?
Very well
Well
Average
Poor
Very poorly
Not sure
3. How important is it to you to do the following in school:
Very
Important
Somewhat
Important
Not very
Important
Not Important
at all
Make friends
Get good grades
Participate in extracurricular activities
Learn new things
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
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SOME OF THE
TIME
If I have a problem at school,
my parents are ready to help.
My parents encourage me to
do well at school.
My parents expect too
much of me at school.
ALL THE TIME
RARELY
MOST OF THE
TIME
NEVER
4. In the next statements, parents can also mean guardians. They are the ones who live with
you at home, take care of your needs, and influence your life.
STRONGLY
DISAGREE
DISAGREE
NEUTRAL
AGREE
STRONGLY
AGREE
5. Please read the next three statements and mark how much you agree or disagree.
At my school, there is a teacher or some other adult
who believes that I will be a success.
My teacher(s) notice when I am doing a good job and
lets me know about it.
There are lots of chances for students in my school to
get involved in sports, clubs, and other activities
outside of class.
There is someone in my life that can help me if I need help.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
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MOST OF THE
TIME
I feel safe on my way
to and from school.
Other young people say
mean things to me at school.
I am bullied in my classroom(s) at school.
I am bullied outside of my classroom(s) at school.
I am bullied on my way
to and from school.
I feel like an outsider
(or left out of things) at
my school.
ALL THE TIME
SOME OF THE
TIME
I feel safe at school.
NEVER
RARELY
6. Read the following statements and choose the answer that best describes how you feel.
We would like to ask you about your family and your experiences with your family. Please
mark the answer that best fits your experiences or how you feel.
7. Including yourself, how many people live in your home? _______
8. Please mark all of the adults that live with you in your home.
Mother
Father
Guardian
Step-mother
Step-father
Grandmother
Grandfather
Uncle
Aunt
Older brother or sister
Other (Please specify) _____________
None of above
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
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NEUTRAL
I regularly share my thoughts and feelings with
someone in my family.
If I had a personal problem, I could ask someone in
my family for help.
Someone in my family notices when I am feeling
upset or sad.
My parent/guardian or someone in my family
notices when I am doing well in school.
People in my family support each other when
times get rough.
My parent/guardian knows the friends that I hang
around with.
I am very close with my family.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
STRONGLY
AGREE
DISAGREE
When I am not at home, one of my family members
knows where I am.
AGREE
STRONGLY
DISAGREE
9. Read the following statements and how much you agree or disagree with the statement
about your family life and involvement with your family.
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C-KABS-Y
We’d like to get a better sense of the community you live in. Some of the statements below
may apply to your community and others will not. Please mark the answer that best matches
how you feel.
STRONGLY
DISAGREE
DISAGREE
NEUTRAL
AGREE
STRONGLY
AGREE
DON”T KNOW
10. Please read the following statements about the community you live in and mark how much
you agree or disagree.
If I needed the advice or help from someone in the
community (not part of your family), it would be
easy for me to get it.
I take pride in my community.
I feel like I belong in my community.
If I needed mental health services, I would know
where to go.
I seek advice from elders when I have a personal
problem.
If I wanted to get some alcohol (beer, wine, or hard
liquor), it would be easy for me to get it.
If I wanted to get some marijuana, it would be easy for
me to get it.
If I wanted to get other illegal drugs (cocaine, heroin, or
crystal meth), it would be easy for me to get it.
Gangs are a serious problem in my community.
Suicide is a frequent problem in my community.
Violence is a frequent problem in my community.
If I wanted to find someone to do a traditional
Native ceremony, I could find a person easily.
If I had a personal challenge or struggle I would feel
comfortable talking to a counselor.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
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We’d like to ask you some questions about how you might respond in various situations with
friends. There are no right or wrong answers. Please mark the answer that best fits how you
think you would react.
DEFINITELY
WOULD
DON’T KNOW
Ask him/her if something was bothering him/her?
Try to get him/her to go talk to a trusted adult
about what’s bothering him/her?
Tell an elder about what you noticed
about your friend?
Tell an adult (not an elder) about what you noticed
about your friend?
Tell another friend about what you noticed
about your friend?
PROBABLY
WOULD
Mind your own business and let your friend
handle the situation on his/her own?
Report the situation to an adult at school
(teacher, principal, school officer)?
Try to get him/her to go talk to a trusted adult?
Tell an elder about what you noticed
about your friend?
Tell an adult you trust (not an elder) about what
you noticed about your friend?
Tell another friend about what you noticed
about your friend?
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
DEFINITELY
WOULD
PROBABLY
WOULD NOT
DEFINITELY
WOULD NOT
12. If a friend was being threatened, bullied, picked on, or physically attacked by another
student on a regular basis, how likely would you be to:
DON’T KNOW
PROBABLY
WOULD
Mind your own business and let him/her
have privacy?
DEFINITELY
WOULD NOT
PROBABLY
WOULD NOT
11. If a friend began to lose interest in activities, other friends, and sometimes said things like
“I’m not much good to anyone,” how likely would you be to:
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C-KABS-Y
DEFINITELY
WOULD
DON’T KNOW
Believe your friend is serious?
Talk to an elder about your friend?
Talk to an adult (not an elder) about your friend?
Talk to that friend without getting anyone else’s help?
Get advice from another friend?
Respect your friend’s privacy and keep it a secret?
PROBABLY
WOULD NOT
Tell your friend to call a hotline?
DEFINITELY
WOULD NOT
PROBABLY
WOULD
13. If a friend told you he/she was thinking about committing suicide how likely would you be
to:
STRONGLY
DISAGREE
DISAGREE
NEUTRAL
AGREE
STRONGLY
AGREE
The next section asks about your thoughts about people who get mental health treatment.
There are no right or wrong answers and your responses will be kept private.
14. Please read the following and indicate how much you agree or disagree.
It is a sign of personal weakness to receive
treatment for suicidal thoughts and behaviors.
I would think less of a person if I found out that
person received treatment for suicidal thoughts
and behaviors.
If you receive mental health treatment, you
shouldn’t tell anyone about it.
I wouldn’t trust someone who received mental
health treatment.
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We’d like to know a little bit more about your life and experiences. These next questions will
ask you about alcohol and drug use. There are no right or wrong answers. No one except the
study team will see your responses, and your name will not be linked with your answers.
NOT AT ALL
LESS THAN ONCE PER MONTH
1–3 TIMES PER MONTH (FOR EXAMPLE,
EVERY OTHER WEEKEND)
1–2 TIMES PER WEEK (FOR EXAMPLE,
EVERY WEEKEND)
3–6 TIMES PER WEEK
DAILY
15. In the past 12 months, how often have you: (Please mark the answer using the legend
below.)
Smoked cigarettes?
Had a drink of alcohol, other than a few sips?
Had more than 5 alcoholic drinks in one sitting?
Used marijuana?
Used methamphetamine (meth, crystal meth, crank)?
Sniffed glue, breathed the contents of spray paint cans,
or inhaled any paints or fumes to get high?
Used Derbisol?
Used other drugs such as cocaine, heroin, or LSD?
Used other people’s prescription drugs to get high,
such as Vicodin, OxyContin,Xanax, Valium, Ritalin,
or Ambien) ?
Been in the ER under the influence of drugs or alcohol?
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
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0 TIMES
1–2 TIMES
3–4 TIMES
5–6 TIMES
7 OR MORE
TIMES
16. In the last 4 weeks, how often have you:
Smoked cigarettes?
Had a drink of alcohol, other than a few sips?
Had more than 5 alcoholic drinks in one sitting?
Used marijuana?
Used methamphetamine (meth, crystal meth, crank)?
Sniffed glue, breathed the contents of spray paint cans,
or inhaled any paints or fumes (like gasoline) to get high?
Used Derbisol?
Used other drugs such as cocaine, heroin, or LSD?
Used other people’s prescription drugs to get high,
such as Vicodin, OxyContin,Xanax, Valium, Ritalin,
or Ambien) ?
Been in the ER under the influence of drugs or alcohol?
Next we’d like to learn a little more about specific activities that you may or may not have
done in the last 12 months.
MORE THAN
ONCE
Been active in sports, clubs, or other activities at school
and/or in my community?
Been honored for something good you did in
your community?
Spent at least one day learning or practicing traditional
Native languages, arts, crafts, or music?
Got an A on an assignment in class?
Set goals for yourself?
NEVER
ONCE
17. In the past 12 months, how often have you:
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Talked to an adult about a challenge you were facing?
Questions 18–22 ask about some serious topics. We know that these are sensitive issues, but
your answers are important to our understanding of your community. If you feel upset by the
questions, Mr./Mrs. NAME, who is here today, can assist you.
First, we’d like to ask you about how you interact with others and your exposure to violence .
No one will know how you answered the questions.
0 TIMES
1–2 TIMES
3–4 TIMES
5–6 TIMES
7 OR MORE
TIMES
18. For each of the following statements, choose how many times you did this activity or it
happened to you in the last 12 months.
I upset other students for the fun of it.
I made other students scared.
In a group, I teased other students.
I fought students I could easily beat.
Other students picked on me.
Other students called me names.
I got hit and pushed by other students.
I enjoyed helping other students.
I helped harass other students.
I cooperated with others.
I teased other students.
I pushed, shoved, slapped, or kicked other students.
I got in a physical fight.
I threatened to hurt or hit another student.
I got into a physical fight because I was angry.
I took my anger out on an innocent person.
I hit back when someone hit me first.
I was mean to someone when I was angry.
I spread rumors about other students.
I started arguments or conflicts.
I encouraged people to fight.
I excluded other students from my group of friends.
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
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C-KABS-Y
5–6 TIMES
7 OR MORE
TIMES
Used words or physically threatened another student
to get what you wanted?
Been in a physical fight in which you were hurt and had
to be treated by a doctor or nurse?
Been in a physical fight that did not involve a weapon?
Been in a physical fight that did involve a weapon?
Carried a weapon, such as a gun or knife, to school?
Been hit, slapped, or physically hurt by a parent,
caregiver, or an adult who lives in your home?
0 TIMES
1–2 TIMES
3–4 TIMES
19. In the past 12 months, how often have you:
20. Have you ever been hit, slapped, or physically hurt by a boyfriend or girlfriend?
Yes
No
I have never had a boyfriend or girlfriend
21. Has anyone ever touched or messed with you or forced you to do something sexually that
you did not want to do?
Yes
No
MORE THAN
ONCE
Next, we would like to ask you questions about suicide. Again, we recognize that some of
these questions might be difficult to answer, but your answers are very important to
understanding your community.
Thought of killing yourself?
ONCE
NEVER
22. In the past 12 months, how often have you:
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Made a plan to kill yourself?
Tried to kill yourself?
This next section asks about kinds of things you do in your community.
SOME OF THE
TIME
Gone fishing?
Gone digging for roots or gathered herbs
or medicines in a traditional Native way?
Gathered berries in a traditional Native way?
Gathered materials for baskets and done basket
weaving in a traditional Native way?
Gone canoeing?
Been to a pow-wow?
Participated in community celebrations?
Participated in potlatches?
Gone to church?
Done traditional native beading?
Gone to a sweat?
Smudged?
Participated in other cultural or spiritual activities?
Please describe
___________________________
___________________________
___________________________
___________________________
ALL THE TIME
RARELY
Gone hunting?
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
MOST OF THE
TIME
NEVER
23. How often have you done the following? [ITEMS WILL BE TAILORED TO FIT COMMUNITY
SPECIFIC ACTIVITIES]
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24. Mark each activity that you participated in during the past 12 months. Mark all that apply.
[ITEMS WILL BE TAILORED TO COMMUNITY SPECIFIC NATIVE ASPIRATIONS ACTIVITIES]
Community Specific Activity 1
Community Specific Activity 2
Community Specific Activity 3
Community Specific Activity 4
Community Specific Activity 5
Other (Please specify) ________________
I did not attend any of these activities
25. Please indicate whether you have been exposed to the following in your community in the
past 12 months. [ITEMS WILL BE TAILORED TO COMMUNITY SPECIFIC NATIVE
ASPIRATIONS ACTIVITIES]
Community Specific Product 1
Community Specific Product 2
Community Specific Product 3
Community Specific Product 4
Community Specific Product 5
Other (Please specify) _________________
I was not exposed to any of these
You are almost finished with the survey. We would like to ask you a few questions about
yourself that will help us understand the whole group of students who take the survey. This
information will not be used to identify you or any individual student.
26. What is your gender?
Female
Male
27. What is your age?
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old or older
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28. What grade are you in?
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12 grade
Ungraded
29. Are you Hispanic or Latino?
Yes [go to question 360]
No [go to question 371]
30. Which Hispanic or Latino group represents you? Are you…(Mark all that apply.)
Mexican, Mexican-American, or Chicano
Puerto Rican
Cuban
Dominican
Central American
South American
Other Hispanic Origin, please describe _________________
31. What is your race? (Mark all that apply.)
American Indian
Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
NEVER
RARELY
SOME OF THE
TIME
MOST OF THE
TIME
ALL THE TIME
32. What languages are spoken in your home?
Tribal language
English
Spanish
Other language
Please specify ______________________
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33. Do you practice traditional Indian/Native beliefs and values?
Yes
No
I don’t know
Thank you for your time and attention to this survey. The information you have provided is
extremely important to suicide, violence, substance use, and bullying prevention efforts in
your community.
To request additional information or if you or someone you know is in
need of help, please contact your school counselor or dial 1-800-273-TALK
Community Knowledge, Awareness, and Behavior Survey (C-KABS) – Youth Version
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| File Type | application/pdf |
| File Title | Suicide Prevention Exposure, Awareness, and Knowledge Survey |
| Author | Christine.M.Walrath |
| File Modified | 2010-09-30 |
| File Created | 2010-09-30 |