Nebraska Risk ad Protective Factor Studet Survey 1. Thak you or agreeig to participate i this survey. The purpose o this survey is to lear how studets i our schools eel about their commuity, amily, peers, ad school. The survey also asks about health behaviors. 2. The survey is completely volutary ad aoymous. DO NOT put your ame o the questioaire. 3. This is ot a test, so there are o right or wrog aswers. We would like you to work quickly so you ca iish. 4. All o the questios should be aswered by completely illig i oe o the aswer spaces. I you do ot id a aswer that its exactly, use the oe that comes closest. I ay questio does ot apply to you, or you are ot sure what it meas, just leave it blak. You ca skip ay questio that you do ot wish to aswer. 5. For questios that have the ollowig aswers: NO! o yes YES! Mark (the BIG) NO! i you thik the statemet is DEFINITELY NOT TRUE or you. Mark (the little) o i you thik the statemet is MOSTLY NOT TRUE or you. Mark (the little) yes i you thik the statemet is MOSTLY TRUE or you. Mark (the BIG) YES! i you thik the statemet is DEFINITELY TRUE or you. Example: Chocolate is the best ice cream lavor. NO! o yes YES! z I the example above, the studet marked "yes" because he or she thiks the statemet is mostly true. 6. Please mark oly oe aswer or each questio by completely illig i the circle with a #2 pecil. Please ill i the ollowig iormatio with the help o your teacher/survey assistat. School: 0 000000000 School District: 0 000000 1 111111111 1 111111 2 222222222 2 222222 3 333333333 3 333333 4 444444444 4 444444 5 555555555 5 555555 6 666666666 6 666666 7 777777777 7 777777 8 888888888 8 888888 9 999999999 9 999999 1. Are you: MALE FEMALE 5. What is your race? (Select oe or more) 2. How old are you? 10 or youger 12 14 16 18 11 13 15 17 19 or older 3. What grade are you i? 6th 7th 8th 9th 10th 11th 12th 4. Are you Hispaic or Latio? Yes (Hispaic or Latio) No (Not Hispaic or Latio) Black, or Arica America Asia America Idia Native Hawaiia or other Paciic Islader Alaska Native White Other (Please Speciy) 6. Where are you livig ow? O a arm or a rach I the coutry, ot o a arm or rach I a city, tow, or suburb O a reservatio Bach Harriso, L.L.C. 116 South 500 East Salt Lake City, Utah, 84102 Phoe: (801) 359-2064 ID
The ext sectio asks about your experieces at school Gamblig 12. Now thikig back over the past year i school, how ote did you: NO! o 14. How importat do you thik the thigs you are learig i school are goig to be or your later lie? yes YES! 7. I my school, studets have lots o chaces to help decide thigs like class activities ad rules. 8. Teachers ask me to work o special classroom projects. 9. There are lots o chaces or studets i my school to get ivolved i sports, clubs, ad other school activities outside o class. 16. How old were you the irst time you gambled (bet moey or somethig o value o sports, a game o chace or skill, played the lottery or bet cards or dice games)? with a teacher oe-o-oe. 17. I the past year, have you gambled or moey or aythig o 11. I have lots o chaces to be value? part o class discussios or activities. Yes No Almost always Ote Sometimes Yes No Seldom 13. How ote do you eel that the school work you are assiged is meaigul ad importat? 15. How iterestig are most o your courses to you? d. Played cards or moey e. Bet moey o horse races Very iterestig ad stimulatig. Played bigo or moey or prizes Quite iterestig g. Gambled o the Iteret Fairly iterestig h. Bet o dice games (such as craps) Slightly dull i. Bet o games o persoal skill Very dull (such as pool, darts or bowlig) 2 18. I the last 30 days, have you gambled or moey or aythig o value? 19. I the past year, have you ote oud yoursel thikig about gamblig or plaig to gamble? 20. I the past year, have you ever spet more tha you meat to o gamblig? 21. I the past year, has your gamblig ever led to lies to your amily? 22. I the past year, how may times (i ay) have you: 12 11 10 or Youger 13 17 or Older 16 15 14 10. There are lots o chaces or studets i my school to talk a. ejoy beig i school? Yes No b. hate beig i school? c. try to do your best work i school? Yes No Yes No Almost every day Oce or twice a week Oce or twice a moth A ew times i past year Gambled, but ot i past year Very importat Quite importat Fairly importat a. Gambled at a casio Slightly importat b. Played the lottery or scratch-o tickets Not at all importat c. Bet o team sports j. Gambled at a school, church, or commuity evet
Health ad Saety 23. How old were you whe you irst: a. smoked marijuaa? b. smoked a cigarette, eve just a pu? c. had more tha a sip or two o beer, wie or hard liquor (or example, vodka, whiskey, or gi)? 17 or older 16 15 14 13 12 11 10 or youger 25. Have you ever beloged to a gag? 26. I you have ever beloged to a gag, did the gag have a ame? No Yes I have ever beloged to a gag No Yes d. bega drikig alcoholic beverages regularly, that is, at least oce or twice a moth? e. used "meth" (also kow as 'crak', 'crystal', or 'ice')?. got suspeded rom school? g. got arrested? h. carried a hadgu? i. attacked someoe with the idea o seriously hurtig them? 27. How may times i the past year (the last 12 moths) have you: 40+ times 30 to 39 times 20 to 29 times 10 to 19 times 6 to 9 times 3 to 5 times 1 to 2 times j. beloged to a gag? a. bee suspeded rom school? 24. How wrog do you thik it is or someoe your age to: a. take a hadgu to school? b. steal aythig worth more tha $5? c. pick a ight with someoe? Not Wrog at All A Little Bit Wrog Wrog Very Wrog b. carried a hadgu? c. sold illegal drugs? d. stole or tried to steal a motor vehicle such as a car or motorcycle? e. bee arrested?. attacked someoe with the idea o seriously hurtig them? d. attack someoe with the idea o seriously hurtig them? e. stay away rom school all day whe their parets thik they are at school? g. bee druk or high at school? h. take a hadgu to school?. drik beer, wie or hard liquor (or example, vodka, whiskey, or gi) regularly (at least oce or twice a moth? g. smoke cigarettes? h. smoke marijuaa? i. used "meth" (also kow as 'crak', 'crystal', or 'ice')? j. use LSD, cocaie, or aother illegal drug? 3
28. You're lookig at CD's i a music store with a ried. 32. I thik sometimes it's okay to cheat at school You look up ad see her slip a CD uder her coat. She smiles ad says "Which oe do you wat? Go ahead, NO! take it while obody's aroud." There is obody i sight, o employees ad o other customers. What would you o do ow? yes Igore her YES! Grab a CD ad leave the store 33. I thik it is okay to take somethig without askig i you ca get away with it. Tell her to put the CD back Act like it is a joke, ad ask her to put the CD back NO! o yes 29. You are visitig aother part o tow, ad you do't kow ay o the people your age there. You are walkig YES! dow the street, ad some teeager you do't kow is walkig toward you. He is about your size, ad as he is about to pass you, he deliberately bumps ito you ad you 34. It is all right to beat up people i they start the ight. almost lose your balace. What would you say or do? NO! Push the perso back o Say "Excuse me" ad keep o walkig yes Say "Watch where you are goig" ad keep o walkig YES! Swear at the perso ad walk away 30. You are at a party at someoe's house, ad oe o your rieds oers you a drik cotaiig alcohol. What would you say or do? 35. How may people your age do you thik... All or almost all o them More tha hal o them About hal o them Less tha hal o them Noe o them Drik it a. smoke cigarettes Tell your ried, "No thaks, I do't drik" ad suggest that you ad your ried go ad do somethig else b. drik beer, wie, or liquor c. smoke marijuaa Just say, "No thaks" ad walk away d. Use "meth" (also kow as 'crak', 'crystal', or 'ice')? Make up a good excuse, tell your ried you had somethig else to do, ad leave 31. It's 8:00 o a weekight ad you are about to go over to a ried's home whe your mother asks you where you are goig. You say "Oh, just goig to go hag out with some rieds." She says, "No, you'll just get ito trouble i you go out. Stay home toight." What would you do ow? 4 36. How much do you thik people risk harmig themselves (physically or i other ways) i they: Great Risk Moderate Risk Slight Risk No Risk a. smoke oe or more packs o cigarettes Leave the house ayway per day? Explai what you are goig to do with your rieds, tell her whe you will get home, ad ask i you ca go out b. try marijuaa oce or twice? c. smoke marijuaa regularly? Not say aythig ad start watchig TV d. take oe or two driks o a alcoholic beverage (beer, wie, liquor) early every Get ito a argumet with her day? e. use "meth" (also kow as 'crak', 'crystal', or 'ice')?
DRUG/ALCOHOL USAGE OCCASIONS O how may occasios (i ay) have you: 0 1-2 3-5 6-9 10-19 20-39 40+ 37. had alcoholic beverages (beer, wie or hard liquor) to drik i your lietime -- more tha just a ew sips? 38. had beer, wie or hard liquor to drik durig the past 30 days? 39. used marijuaa (grass, pot) or hashish (hash, hash oil) i your lietime? 40. used marijuaa (grass, pot) or hashish (hash, hash oil) durig the past 30 days? 41. used LSD or other psychedelics i your lietime? 42. used LSD or other psychedelics durig the past 30 days? 43. used cocaie or crack i your lietime? 44. used cocaie or crack durig the past 30 days? 45. take 'meth' (also kow as 'crak', 'crystal', or 'ice') i your lietime? 46. take 'meth' (also kow as 'crak', 'crystal', or 'ice') i the past 30 days? 47. sied glue, breathed the cotets o a aerosol spray ca, or ihaled other gases or sprays, i order to get high i your lietime? 48. sied glue, breathed the cotets o a aerosol spray ca, or ihaled other gases or sprays, i order to get high durig the past 30 days? 49. used pheoxydie (pox, px, breeze) i your lietime? 50. used pheoxydie (pox, px, breeze) durig the past 30 days? 51. used steroids without a doctor tellig you to take them, i your lietime? 52. used steroids without a doctor tellig you to take them, durig the past 30 days? 53. used perormace ehacig drugs other tha steroids (such as ephedrie, EPO, creatie, DHEA, or diuretics) without a doctor tellig you to take them, i your lietime? 54. used perormace ehacig drugs other tha steroids (such as ephedrie, EPO, creatie, DHEA, or diuretics) without a doctor tellig you to take them, durig the past 30 days? 55. used prescriptio drugs (such as valium, Xaax, Ritali, Adderall, Oxycoti, or sleepig pills) without a doctor tellig you to take them, i your lietime? 56. used prescriptio drugs (such as valium, Xaax, Ritali, Adderall, Oxycoti, or sleepig pills) without a doctor tellig you to take them, durig the past 30 days? 57. used other illegal drugs i your lietime? 58. used other illegal drugs durig the past 30 days? 59. Drive a car, truck, or motorcycle ater drikig alcohol durig the past year? 60. bee a passeger i a car, truck, or o a motorcycle drive by someoe who had bee drikig alcohol durig the past year? 61. Thik back over the last two weeks. How may times have you had ive or more alcoholic driks i a row? 63. How requetly have you used smokeless tobacco durig the past 30 days? Noe 3-5 times Oce 6-9 times Twice 10 or more times Oce or twice 62. Have you ever used smokeless tobacco (chew, su, plug, dippig tobacco, or chewig tobacco)? Oce or twice per week Three to ive times a week Regularly i the past About oce a day Oce or Twice Regularly ow Oce i a while but ot regularly 5 More tha oce a day
64. I you drak alcohol (ot just a sip or a taste) i the past year, thik about the last time you did so. How did you get the alcoholic beverage? (Check Yes or No or each. I you did ot drik alcohol i the past year, check Did Not Use or each oe). Did Not Use 67. I you smoked a cigarette i the past year, thik about the last time you did so. At that time, how did you get the cigarette? (Check Yes or No or each. I you did ot smoke a cigarette i the past year, check Did Not Use or each oe). The last time I smoked a cigarette... The last time I drak alcohol... Yes No a. I bought it mysel with a ake ID a. I bought it mysel with a ake ID b. I bought it mysel without a ake ID b. I bought it mysel without a ake ID c. I got it rom someoe I kow aged 18 or older c. I got it rom someoe I kow aged 21 or older d. I got it rom someoe I kow uder age 18 d. I got it rom someoe I kow uder age 21 e. I got it rom a brother or sister e. I got it rom a brother or sister. I got it rom home with my parets' permissio. I got it rom home with my parets' permissio g. I got it rom home without my parets' permissio g. I got it rom home without my parets' permissio h. I got it rom aother relative h. I got it rom aother relative i. A strager bought it or me i. A strager bought it or me j. I took it rom a store or shop j. I took it rom a store or shop k. I got it rom a vedig machie k. Other l. Other Yes No Did Not Use 65. Ad at the time you last drak alcohol i the past year, where were you whe you last drak? (Check Yes or No or each. I you did ot drik alcohol i the past year, check Did Not Use or each oe). 68. Ad at the time you last smoked a cigarette i the past year, where were you whe you smoked it? (Check Yes or No or each. I you did ot smoke a cigarette i the past year, check Did Not Use or each oe). O the last day I had alcohol, I drak... Yes No Did Not Use O the last day I smoked a cigarette, I was... Yes No Did Not Use a. at my home b. at someoe else's home c. at a ope area like a park, beach, back road, or a street corer d. at a sportig evet or cocert e. at a restaurat, bar or a ightclub. at a empty buildig or a costructio site g. at a hotel/motel h. I a car a. at my home b. at someoe else's home c. at a ope area like a park, beach, back road, or a street corer d. at a sportig evet or cocert e. at a restaurat, bar or a ightclub. at a empty buildig or a costructio site g. at a hotel/motel h. I a car 66. O the last day you had alcohol, were there oe or more adults preset? 69. O the last day you smoked a cigarette, were there oe or more adults preset? Yes No used Yes No Used 6
70. Have you ever smoked cigarettes? Oce or Twice Oce i a while but ot regularly Regularly i the past Regularly ow 74. Which o the ollowig activites or people your age are available i your commuity? a. sports teams b. scoutig c. boys ad girls clubs No Yes No Yes No Yes 71. How requetly have you smoked cigarettes durig the past 30 days? d. 4-H clubs e. service clubs No Yes No Yes Not at all. Other activites or clubs led or orgaized by adults No Yes Less tha oe cigarette per day Oe to ive cigarettes per day No! o yes Yes! About oe-hal pack per day About oe pack per day 75. I eel sae i my eighboorhood, or the area aroud where I live. About oe ad oe-hal packs per day 76. There are lots o adults i my eighborhood I could talk to about Two packs or more per day somethig importat. Commuity-Based Perceptios 77. I a kid smoked marijuaa i your eighborhood, or area aroud where you live, would he or she be caught by the police? 72. How wrog would most adults i your eighborhood, or the area aroud where you live, thik it is or kids your age: Not Wrog at All A Little Bit Wrog Wrog Very Wrog a. to use marijuaa? b. to drik alcohol? c. to smoke cigarettes? d. to use "meth"? 78. I a kid drak some beer, wie or hard liquor (or example, vodka, whiskey, or gi) i your eighborhood, or area aroud where you live, would he or she be caught by the police? 79. I a kid smoked cigarettes i your eighborhood, or the area aroud where you live, would he or she be caught by the police? 80. I a kid carried a hadgu i your eighborhood, or area aroud where you live, would he or she be caught by the police? 81. I my commuity there are may u or iterestig thigs to do that are sae ad legal. 73. How much do each o the ollowig statemets describe your eighborhood, or the area aroud where you live? 82. I you wated to get some cigarettes, how easy would it be or you to get some? very easy sort o easy sort o hard very hard a. crime ad/or drug sellig NO! o yes YES! 83. I you wated to get some beer, wie or hard liquor (or example, vodka, whiskey, or gi), how easy would it be or you to get some? b. ights c. lots o empty or abadoed buildigs d. lots o graiti 84. I you wated to get a drug like cocaie, LSD, or amphetamies, how easy would it be or you to get some? 85. I you wated to get a hadgu, how easy would it be or you to get oe? 7 86. I you wated to get some marijuaa, how easy would it be or you to get some?
100. How importat were these questios? Family Domai Not too Importat Fairly importat Importat Very importat I the ext ew questios, "amily" reers to parets, brothers, sisters, other relatives, ad other persos that are close to you, ad who you live with at least part o the year. "Parets" reers to either your actual parets or persos who are like parets to you. 101. How hoest were you i illig out this survey? 87. How wrog do your parets Not wrog at all eel it would be or you to: A little bit wrog Wrog Very wrog a. drik beer, wie or hard liquor (or example, vodka, whiskey or gi) regularly (at least oce or twice a moth)? b. smoke cigarettes? c. smoke marijuaa? I was very hoest I was hoest pretty much o the time I was hoest some o the time I was hoest oce i a while I was ot hoest at all Thak you or completig the survey d. Use "meth"? No! o yes YES! 88. The rules i my amily are clear. 89. Whe I am ot at home, oe o my parets kows where I am ad who I am with. 90. My parets wat me to call i I am goig to be late gettig home. 91. My amily has clear rules about alcohol ad drug use. 92. My parets ask me what I thik beore most amily decisios aectig me are made. 93. Do you eel very close to oe or more o your parets? 94. Do you share your thoughts ad eeligs with oe or more o your parets? 95. I I had a persoal problem, I could ask oe or more o my parets or help 96. My parets give me lots o chaces to do u thigs with them. 97. My parets ask i I've gotte my homework doe. 98. Would your parets kow i you you did ot come home o time? 99. It is importat to be hoest with your parets, eve i they become upset or you get puished. 8