Appendix F: Middle School Survey Instrument
1. How old are you:
10 years old or younger
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old or older
2. What is your sex?
Male
Female
3. In what grade are you?
6th grade
7th grade
8th grade
4. What is your race/ethnicity? (Select all that apply)
American Indian / Alaskan Native
Asian
Black / African-American
Hispanic / Latino
Native Hawaiian or Other Pacific Islander
White / Caucasian
Other (Please specify) ______
5. How tall are you without shoes on?
Feet: ______
Inches: ______
6. How much do you weigh without shoes on?
Weight: ______
The next questions ask about safety.
7. When you rode a bicycle, rollerblades, skateboard or four-wheeler (ATV) during the past 12 months, how often did you wear a helmet?
I did not ride a bicycle, rollerblades, skateboard or four wheeler
Never wore a helmet
Rarely wore a helmet
Sometimes wore a helmet
Most of the time wore a helmet
Always wore a helmet
8. How often do you wear a seatbelt when riding in a car?
Never
Rarely
Sometimes
Most of the time
Always
9. Have you ever ridden in a car driven by someone who has been drinking alcohol?
Yes
No
Not sure
The next questions ask about violence-related behaviors.
10. Have you ever carried a weapon, such as a gun, knife, or club?
Yes
No
11. Have you ever been in a physical fight?
Yes
No
12. Have you ever been in a physical fight in which you were hurt and had to be treated by a doctor or nurse?
Yes
No
The next questions ask about bullying. Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. 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.
13. During the past 12 months, have you ever been bullied?
Yes
No
14. Do you use any social networking sites, like Facebook, MySpace or Twitter?
Yes
No
15. How many times in the past 6 months have you been the victim of cyber-bullying (bullying through text message, Facebook, MySpace, or other websites)?
Never
Once
2-3 times
4-6 times
7-10 times
More than 10 times
16. During the past 12 months, did your boyfriend or girlfriend ever hit, slap or physically hurt you on purpose?
Yes
No
17. Have you ever been physically forced to have sexual intercourse when you did not want to?
Yes
No
The next questions will ask about tobacco use.
18. Have you ever tried cigarette smoking, even one or two puffs?
Yes
No
19. Does anyone in your household smoke cigarettes?
Yes
No
20. 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 or older
21. During the past 30 days, on how many days did you smoke cigarettes?
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
22. 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
2-5 cigarettes per day
6-10 cigarettes per day
11-20 cigarettes per day
More than 20 cigarettes per day
23. 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 (or bummed) them from someone else
My parents bought them for me
Another person 18 years old or older gave them to me
I took them from a store or family member
I got them some other way (Please specify ______)
24. Have you smoked cigarettes daily, that is, at least one cigarette every day for 30 days?
Yes
No
25. During the past 30 days, on how many days did you use chewing tobacco, snuff or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
26. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
0 days
1-2 days
3-5 days
6-9 days
10-19 days
20-29 days
All 30 days
The next 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.
27. Have you ever had a drink of alcohol, other than a few sips?
Yes
No
28. 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
9-10 years old
11-12 years old
13-14 years old
15-16 years old
17 years old or older
29. 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 bought it in a store, such as a liquor store, convenience store, supermarket, discount store, or gas station
I bought it at a restaurant, bar or club
I bought it at a public event, such as a concert or sporting event
I gave someone else money to buy it for me
A parent bought it for me
Someone gave it to me
I took it from a store or family member
I got it some other way (Please specify ______)
The next questions ask about drug use.
30. Has anyone ever tried to sell or give you an illegal drug?
Yes
No
31. Have you ever used marijuana? (Also called grass or pot)
Yes
No
32. How old were you when you tried marijuana for the first time?
I have never tried marijuana
8 years old or younger
9-10 years old
11-12 years old
13-14 years old
15-16 years old
17 years of age or older
33. Have you ever used any form of cocaine, including powder, crack, or freebase?
Yes
No
34. Have you ever sniffed glue, or breathed the contents of spray cans, or inhaled any paints or sprays to get high?
Yes
No
35. Have you ever used steroid pills or shots without a doctor’s prescription?
Yes
No
36. Have you ever used heroin (also called smack, junk, or China White)?
Yes
No
37. Have you ever used methamphetamines (also called speed, crystal, crank, or ice)?
Yes
No
38. Have you ever used ecstasy (also called MDMA)?
Yes
No
39. Have you ever taken prescription drugs that were not prescribed to you in order to get high?
Yes
No
40. How did you get the prescription pills that you took in order to get high?
I have never used prescription pills in order to get high
I took them from my medicine cabinet without my parent’s knowledge
My parents gave them to me
A friend gave them to me
I stole them from a store, such as a pharmacy, convenient store, or grocery store
I got it some other way (Please specify ______)
41. Have you ever sent or received sexually explicit pictures or video on your cell phone of yourself or another person (also known as sexting)?
Yes
No
The next questions will ask about body weight.
42. How do you describe your weight?
Very underweight
Slightly underweight
About the right weight
Slightly overweight
Very overweight
43. 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
44. Have you ever exercised to lose weight or to keep from gaining weight?
Yes
No
45. Have you ever eaten less food, fewer calories, fewer carbs, or foods low in fat to lose weight or to keep from gaining weight?
Yes
No
46. Have you ever gone without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?
Yes
No
47. Have you ever taken 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
48. Have you ever vomited or taken laxatives to lose weight or to keep from gaining weight?
Yes
No
The next questions will 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.
49. During the past 7 days, how many times did you drink 100% fruit juices such as orange juice, apple juice, or grape juice? (Do not count punch, Kool-Aid, sports drinks, or other fruit-flavored drinks)
I did not drink 100% fruit juice during the past 7 days
1-3 times during the past 7 days
4-6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day
50. 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
1-3 times during the past 7 days
4-6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day
51. During the past 7 days, how many times did you eat vegetables? (such as salads, carrots, or other vegetables)
I did not eat vegetables during the past 7 days
1-3 times during the past 7 days
4-6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day
52. During the past 7 days, how many times did you eat potatoes? (Do not count french fries, fried potatoes, or potato chips.)
I did not eat potatoes during the past 7 days
1-3 times during the past 7 days
4-6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day
53. During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not include diet soda or diet pop.)
I did not drink soda or pop during the past 7 days
1-3 times during the past 7 days
4-6 times during the past 7 days
1 time per day
2 times per day
3 times per day
4 or more times per day
54. During the past 7 days, how many glasses of milk did you drink? (Include the milk you drank in a glass or cup, from a carton, or with cereal. Count the half pint of milk served at school as equal to one glass.)
I did not drink milk during the past 7 days
1-3 glasses during the past 7 days
4-6 glasses during the past 7 days
1 glass per day
2 glasses per day
3 glasses per day
4 or more glasses per day
55. During the past 7 days, how many times did you drink an energy drink, such as Red Bull, Monster, or Five Hour Energy?
I did not drink an energy drink during the past 7 days
1-3 glasses during the past 7 days
4-6 glasses during the past 7 days
1 glass per day
2 glasses per day
3 glasses per day
4 or more glasses per day
The next questions will ask about physical activity.
56. 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
57. 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 or more hours per day
58. On an average school day, how many hours do you play video or computers games or use a computer for something that is not school work? (Include activities such as Nintendo, Game Boy, PlayStation, Xbox, computer games, 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 or more hours per day
59. In an average week when you are in school, on how many days do you go to physical education (PE) classes?
0 days
1 day
2 days
3 days
4 days
5 days
60. During the past 12 months, on how many sports teams did you play? (Include any teams run by your school or community groups)
0 teams
1 team
2 teams
3 or more teams
The next questions will ask about mental health.
61. During the past 12 months, have you ever had a hard time concentrating on completing a task?
Yes
No
62. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?
Yes
No
63. During the past 12 months, did you ever seriously consider attempting suicide?
Yes
No
64. During the past 12 months, how many times did you actually attempt suicide?
0 times
1 time
2-3 times
4-5 times
6 or more times
65. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?
Yes
No
Did not attempt suicide during the past 12 months
66. When you feel sad, hopeless, or depressed, with whom do you talk about your concerns? (Select all that apply)
No one
Best friend
My girlfriend/boyfriend
Pastor/priest
Brother/sister
Parents
Youth minister
Scout master
Teacher
School counselor
Professional counselor
Other (Please Specify______)
67. During your life, how many times have you purposely hurt yourself? (for example, cutting, burning, scratching, hitting, biting, etc)
0 times
1-2 times
3-9 times
10-19 times
20-39 times
40 times or more
The next questions will ask about other health-related topics.
68. Have you ever been taught about AIDS or HIV infection in school?
Yes
No
Not sure
69. Has a doctor or nurse ever told you that you have asthma?
Yes
No
Not sure
70. Do you still have asthma?
I have never had asthma
Yes
No
Not sure
71. How long has it been since you last visited the dentist or a dental clinic for any reason?
Never
Less than 1 year ago
1 year, but less than 2 years ago
2 years, but less than 5 years ago
5 or more years ago
72. Outside of school, what kinds of things do you do for fun in Darke County? (Open-ended Question)
Thank you for completing this survey!
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