HEALTHY TEENS SURVEY

We are interested in learning more about your thoughts, opinions, and feelings about health and what you do to stay healthy. We hope you will help us by completing this survey. We will use these answers to educate the public and improve school health education programs. Any information released concerning this survey will contain information about the 10^th grade class as a whole. None of your personal answers will be available to anyone at any time. So please DO NOT put your name anywhere on this questionnaire. Whether or not you answer the questions will not affect your grades. If you decide not to participate, your teacher will provide you with some other activity during this class. However, we really need your help to keep young people healthy!

* Please remember:

• Do not put your name on this form.

• Your answers are private. We will not tell anyone what you write.

• You are not being graded on this exercise.

• Please take your time and answer carefully.

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SECTION A: Please check only one answer per question

A1. Gender 1_____Male 2_____Female

A2. Age __________

A3. Who do you live with most of the time?

1_____I live with both parents 4_____I live with 1 parent & 1 stepparent

2_____I live with my mother 5_____I live with other relatives/guardians

3_____I live with my father 6_____I split time between my parents

7_____Other________________________

A4. How often do you attend church/religious services?

1_____I have never attended church 5_____2 –3 times a month

2_____About once or twice a year 6_____Every week

3_____Several times a year 7_____Several times a week

4_____About once a month 8_____I am not currently attending church

A5. What do you think is the biggest concern among teenagers today?

_____________________________________________________________________________

______________________________________________________________________________

SECTION B: Below are some statements about AIDS. For each question, please circle the answer you think is correct. Remember, we are interested in what YOU think.

	True	False	Don’t Know
B1. Only people who look sick can spread the AIDS virus.	1	2	3
B2. Condoms reduce the risk of getting the AIDS virus.	1	2	3
B3. A person can get the AIDS virus even if he or she has sexual intercourse just one time without a condom.	1	2	3
B4. A person can get AIDS by touching or hugging someone with AIDS.	1	2	3
B5. Most people who have the AIDS virus show signs of being sick right away.	1	2	3
B6. You can get AIDS by having anal sex without a condom.	1	2	3
B7. You can get AIDS by being bitten by a mosquito that has bitten someone with AIDS.	1	2	3
B8. Only people who have sexual intercourse with gay (homosexual) people get AIDS.	1	2	3
B9. You can get AIDS from kissing someone who has AIDS.	1	2	3
B10. You can get AIDS by having sexual intercourse with someone who has shared drug needles.	1	2	3
B11. Birth control pills protect a woman from getting the AIDS virus.	1	2	3

B12. Where have you learned about AIDS? Please check all that apply.

1_____School 10_____Parents or adult relatives

2_____Television 11_____Sisters, brothers, or teenage relatives

3_____Radio 12_____Boyfriend/girlfriend

4_____Doctors 13_____Pamphlets or flyers

5_____Church 14_____Billboards

6_____Friends 15_____Internet

7_____Newspapers or magazines 16_____None, No learning

8_____Movies 17_____Other (please describe)_______________

9_____Books _________________________________

SECTION C: Below are some questions about expressing your opinions to others. You may not have actually done these things, but we would like you to tell us how confident you are that you WOULD do them. Please only circle one answer for each question.

C1. Would you talk with your friends about the following topics without being embarrassed: someone you would like to have as a boyfriend or girlfriend, sex, condoms, AIDS, and other sexually transmitted diseases?

I definitely I probably I probably I definitely

would not would not would would

1 2 3 4

C2. Would you talk with your boyfriend /girlfriend about the following topics without being embarrassed: sex, condoms, AIDS, and sexually transmitted diseases?

I definitely I probably I probably I definitely

would not would not would would

1 2 3 4

C3. Would you ask someone you like romantically to spend time with you or go out with you?

I definitely I probably I probably I definitely

would not would not would would

1 2 3 4

C4. Would you tell your boyfriend/girlfriend that you don't want to make out with him/her, to stop touching you sexually, or that you don’t want to have sex?

I definitely I probably I probably I definitely

would not would not would would

1 2 3 4

C5. How comfortable do you feel talking with your parent(s) or the adult(s) you live with about sex, sexually transmitted diseases, AIDS, pregnancy, and using condoms?

I feel I feel I feel I feel

very somewhat somewhat very

uncomfortable uncomfortable comfortable comfortable

1 2 3 4

SECTION D: These questions are about you and your parent(s) or the adult(s) you live with. Have you ever talked with your parent(s) or the adult(s) you live with about the following topics? Please circle only one response for each question.

	Yes	No
D1. Have you ever talked with your parent(s) or the adult(s) you live with about sex or using condoms?	1	2
D2. Have you ever talked with your parent(s) or the adult(s) you live with about diseases you can get from having sexual intercourse?	1	2
D3. Have you ever talked with your parent(s) or the adult(s) you live with about pregnancy?	1	2

SECTION E: Please circle the answer that shows how worried you will be when you become sexually active.

	Not at all worried	Somewhat worried	Very worried
E1. How worried are you that you might get AIDS?	1	2	3
E2. How worried are you that you might get a disease from having sex?	1	2	3
E3. How worried are you that you might get pregnant if you are a girl, or that you might get a girl pregnant if you are a boy?	1	2	3

SECTION F: Please circle the answer that shows how worried you will be when you become sexually active.

	No Chance At All	Might Happen	Very Likely to Happen
F1. What do you think the chances are that you will get a sexually transmitted disease someday?	1	2	3
F2. What do you think the chances are that you will get pregnant or get a girl pregnant before you are 20?	1	2	3

SECTION G: We are interested in your thoughts about what your FRIENDS (or the kids you hang around with) think and do. You may not know exactly what they think or do. That’s okay. Just put down your best guess. Circle only one answer for each question.

	None	A few	About half	Most	All
G1. How many of your friends think condoms are too much trouble to use?	1	2	3	4	5
G2. How many of your friends do you think have had sexual intercourse?	1	2	3	4	5
G3. How many of your friends do you think use condoms when they have sex?	1	2	3	4	5

SECTION H: Please circle the answer that best describes how you feel about abstinence.

	YES	NO
H1. I believe it is possible to wait until marriage to have sexual intercourse?	1	2
H2. I think there are benefits of waiting until marriage to have sexual intercourse?	1	2
H3. I plan to save sexual intercourse for marriage	1	2

SECTION I: Now we’d like to know what you think is true about condoms. You may have used them before or maybe not, but tell us what you think. For each statement, please circle only one answer.

	They definitely do not	They probably do not	They probably do	They definitely do
I1. Condoms break easily.	1	2	3	4
I2. If you choose to have sexual intercourse, using condoms correctly helps reduce the risk of getting the AIDS virus and other diseases you can get from sex.	1	2	3	4
I3. Condoms slip off easily.	1	2	3	4

SECTION J: The following questions relate to your experience with sexual intercourse. Please check only one answer per question. If you have never had sexual intercourse, please check the box next to the statement “I have never had sexual intercourse” below and skip to Section K.

I have never had sexual intercourse (Check this box, then Skip to Section K)

J1. How young were you the first time you had sexual intercourse? Please write your age at that time in the space below.

. I was ____ years old the first time I had sexual intercourse.

J2. How many different people have you had sexual intercourse with in your lifetime?

1_____1 person 3_____4-5 people 5_____8-9 people

2_____2-3 people 4_____6-7 people 6_____10 or more people

J3. How often do you have sexual intercourse?

1_____About once a month or less 4_____3 times a week or more

2_____2-4 times a month 5_____I am not currently having sex

3_____Twice a week

J4. If you're a boy, how often do you use a condom (rubber) when you have sexual intercourse? Or if you're a girl, how often does the guy use a condom when you have sexual intercourse?

1_____Always 4_____Less than half the time

2_____More than half the time 5_____Never

3_____About half the time 6_____I am not currently having sex

J5. Did you or the other person use a condom (rubber) the last time you had sexual intercourse?

1_____Yes 2_____No

J6. Have you ever had oral sex? 1_____Yes 2_____No

J7. Do you think oral sex is “sex”? 1_____Yes 2_____No

J8. Have you had sexual intercourse in the past 2 months?

1_____Yes 2_____No

J9. In the last two months, did you or your partner use any of the following methods to prevent pregnancy?

Yes No

Condoms...................................................................................... 1 2

Birth control pills............................................................................ 1 2

Withdrawal ("pulling out").............................................................. 1 2

Sexual intercourse with no method of birth control.......................... 1 2

SECTION K: The following questions relate to your experience with alcohol. Please check only one answer for each question. If you have never have more than a sip or taste of alcohol, just check the box next to the statement I have never had more than a sip or taste of alcohol below and skip to Section L.

I have never had more than a sip or taste of alcohol (Check this box, then Skip to Section L)

K1. How old were you when you first tried alcohol (not just a sip or a taste)? Please write your age at that time in the space below.

I was _________ years old the first time I tried alcohol.

K2. How often do you drink alcohol?

1_____I am not currently drinking alcohol 5_____Once or twice a week

2_____ Only on religious occasions 6_____3 times or more a week

3_____A few times a year 7_____Every day

4_____Once or twice a month

K3. In the past 30 days have you ridden in a car with a driver who had been drinking?

1_____Yes 2_____No

K4. In the past 30 days have you driven a car after drinking alcohol?

1_____Yes, I drove a car after drinking alcohol

2_____No, I did not drive a car after drinking alcohol

3_____No, I did not drink in the past 30 days

K5. If you have ever drunk alcohol before having sexual intercourse, how often did you or your partner use a condom after drinking?

1_____Always used a condom 4_____Usually didn't use a condom

2_____Usually used a condom 5_____Never used a condom

3_____Used a condom about half of the time

I have never had sexual intercourse after drinking

SECTION L: The following questions relate to your experience with cigarettes. Please check only one answer for each question. If you have never tried smoking, just check the box next to the statement I have never tried smoking a cigarette below and skip to Section M.

I have never tried smoking a cigarette (Check this box, then Skip to Section M)

L1. How old were you when you smoked a whole cigarette for the first time?

1_____I have never smoked a whole cigarette 5_____13 or 14 years old

2_____8 years old or younger 6_____15 or 16 years old

3_____9 or 10 years old 7_____17 years old or older

4_____11 or 12 years old

L2. During the past 30 days, on how many days did you smoke cigarettes?

1_____1 or 2 days 5_____20 to 29 days

2_____3 to 5 days 6_____All 30 days

3_____6 to 9 days 7_____I did not smoke cigarettes

4_____10 to 19 days

L3. During the past 30 days, how did you usually get your own cigarettes?

Please check only one answer.

1_____I do not smoke

2_____I bought them from a store

3_____I bought them from a vending machine

4_____I gave someone else money to buy them

5_____I borrowed (or bummed) them from a person 18 years or older

6_____I borrowed (or bummed) them from a person younger than 18

7_____I took them from a store

8_____I got them in some other way (please explain)_____________________________

L4. During the past 30 days, where did you buy the last pack of cigarettes you bought?

1_____I do not smoke 5_____A vending machine

2_____I did not buy a pack of cigarettes 6_____I bought them over the internet

3_____A gas station 7_____A grocery store

4_____A drug store 8_____Other (please explain)____________

SECTION M: The following questions relate to your experience with marijuana. Please check only one answer for each question. If you have never tried marijuana, just check the box next to the statement I have never tried marijuana below and skip to Section N.

I have never tried marijuana (Check this box, then Skip to Section N)

M1. How old were you the first time you tried marijuana? Please write your age at that time in the space below.

I was _________ years old the first time I used marijuana

M2. How often do you use marijuana?

1_____ I am not currently using marijuana 5_____Once or twice a week

2_____A few times a year 5_____3 times or more a week

3_____Once or twice a month 6_____Every day

M3. If you have ever smoked marijuana before having sexual intercourse, how often did you or your partner use a condom after smoking?

1_____Always used a condom 4_____Usually didn't use a condom

2_____Usually used a condom 5_____Never used a condom

3_____Used a condom about ½ of the time I’ve never had sex after smoking marijuana

SECTION N: Please check only one answer for the following questions.

N1. How often do you log onto a social networking site (MySpace, Facebook, etc)?

1_____Never 4_____Once a day

2_____Once or twice a month 5_____More than once a day

3_____Once or twice a week 6_____Other_________________

N2. How old are the boys or girls you go out with on dates? Please check only one answer.

1_____Younger than me by 3 or more years

2_____A little younger than me (1-2 years)

3_____My age

4_____A little older than me (1-2 years)

5_____Older than me by 3 or more years

6_____I have never gone out with anyone

N3. How old are most of your friends? Please check only one answer.

1_____Younger than me by 3 or more years

2_____A little younger than me (1-2 years)

3_____My age

4_____A little older than me (1-2 years)

5_____Older than me by 3 or more years

SECTION O: The following questions relate to your experiences with physical and emotional abuse. Please circle one answer for each question

	YES	NO
O1. Have any of your friends ever been physically abused by a boyfriend/girlfriend?	1	2
O2. Have you ever been physically abused by a boyfriend/girlfriend?	1	2
O3. Have you ever been forced to have sexual intercourse when you did not want to?	1	2
O4. Have any of your friends ever been emotionally abused by a boyfriend/girlfriend (ex. name calling, humiliation, etc)?	1	2
O5. Have you ever been emotionally abused by a boyfriend/girlfriend (ex: name calling, humiliation, etc)?	1	2
O6. Have you ever been a victim of bullying at school?	1	2

SECTION P: Please circle the answer that best describes your feelings.

	YES	NO
P1. 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 going some usual activities?	1	2
P2. Have you ever cut yourself, or hurt yourself in some other way on purpose (including cutting)?	1	2
P3. During the past 12 months, did you ever seriously consider attempting suicide?	1	2
P4. During the past 12 months, did you ever make a plan about how you would attempt suicide?	1	2
P5. During the past 12 months, did you actually attempt suicide?	1	2

SECTION Q: Please circle the answer that shows how you feel at school.

	YES	NO
Q1. At school there are adults I can talk to, who care about my feelings and what happens to me.	1	2
Q2. Most of the students here respect me	1	2
Q3. Most of the teachers here respect me.	1	2
Q4. I feel safe at school.	1	2

You’re Finished! Thank You for Your Help!