1. PNRC
Adolescent
Outcome
Measures
v8
5/30/2010
1
PNRC
Adolescent
Survey
This
survey
is
about
your
health
and
health
behavior.
It
has
been
developed
so
you
can
tell
us
what
you
do
that
may
affect
your
health.
The
information
you
give
will
be
used
to
develop
better
health
education
for
young
people
like
yourself.
DO
NOT
write
your
name
on
this
survey.
The
answers
you
give
will
be
kept
private.
No
one
will
know
what
you
write.
Answer
the
questions
based
on
what
you
really
do.
Completing
the
survey
is
voluntary.
Whether
or
not
you
answer
the
questions
will
not
affect
your
grade
in
this
class.
If
you
are
not
comfortable
answering
a
question,
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.
Make
sure
to
read
every
question.
Fill
in
the
ovals
completely.
When
you
are
finished,
follow
the
instructions
of
the
person
giving
you
the
survey.
Thank
you
very
much
for
your
help.
2. PNRC
Adolescent
Outcome
Measures
v8
5/30/2010
2
1. How
old
are
you?
A.
12
years
old
or
younger
B.
13
years
old
C.
14
years
old
D.
15
years
old
E.
16
years
old
F.
17
years
old
G.
18
years
old
or
older
2. What
is
your
sex?
A.
Female
B.
Male
3. Are
you
Hispanic
or
Latino?
A.
Yes
B.
No
4. What
is
your
race?
(Select
one
or
more
responses.)
A.
American
Indian
or
Alaska
Native
B.
Asian
C.
Black
or
African
American
D.
Native
Hawaiian
or
Other
Pacific
Islander
E.
White
5.
Internet
Access
a. Do
you
have
internet
access
in
your
home?......................................
b. Do
you
have
internet
access
at
your
school?
……………………………….
c. How
often
do
you
use
the
internet
for
school
work
such
as
doing
homework,
reports,
projects?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
d. How
often
do
you
use
the
internet
for
non-‐school
related
activity
such
as
surfing
the
web,
looking
up
things,
sending
email?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
6. Sleep
a. What
time
do
you
usually
go
to
bed
in
the
evening
on
weekdays
(turn
out
the
lights
in
order
to
sleep)?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
b. What
time
do
you
usually
get
out
of
bed
in
the
morning
on
the
weekdays?
-‐-‐-‐-‐-‐-‐-‐
No
Yes
1
2
1
2
Never
Sometimes
Almost
Everyday
0
1
2
3
4
0
1
2
3
4
:
:
3. PNRC
Adolescent
Outcome
Measures
v8
5/30/2010
3
7.
Parent
relationships
In
general,
how
often
does
your
parent
know:
a. what
you
are
doing
when
you
are
away
from
home?
-‐-‐-‐
b. where
you
are
after
school?-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
c. your
interests
and
things
you
like
to
do?-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
d. your
plans
for
the
day?-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
e. In
the
last
2
days,
how
often
did
your
parent’s
know
your
whereabouts
and
activities?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
Family
Cohesion
f. I
listen
to
what
my
parents
say
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
g. My
family
members
help
each
other
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
h. My
family
members
like
to
spend
time
with
each
other
i. My
family
members
feel
close
to
each
other
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
Family
Conflict
j. In
my
family
we
often
yell
at
each
other
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
k. My
family
members
argue
a
lot
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
l. We
argue
about
the
same
things
over
and
over
in
my
family
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
8.
Prosociality
a. I
think
it
is
important
to
help
other
people.
......................................
b. I
resolve
conflicts
without
anyone
getting
hurt.
...............................
c. I
tell
the
truth
even
when
it
is
not
easy.
............................................
d. I
am
helping
to
make
my
community
a
better
place.
........................
e. I
am
trying
to
help
solve
social
problems.
.........................................
f. I
am
developing
respect
for
other
people.
........................................
g. I
am
sensitive
to
the
needs
and
feelings
of
others.
...........................
h. I
am
serving
others
in
my
community.
..............................................
Never
sometimes
Always
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Never
Sometimes
Always
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Never
Sometimes
Always
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Not
true
Sometimes
True
Always
True
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
4. PNRC
Adolescent
Outcome
Measures
v8
5/30/2010
4
9.
Behaviors
In
the
past
30
days:
a. on
how
many
days
did
you
carry
a
weapon? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
b. on
how
many
days
did
you
smoke
cigarettes? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
c. on
how
many
days
did
you
have
at
least
one
drink
of
alcohol? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
d. on
how
many
days
did
you
have
5
or
more
drinks
of
alcohol
in
a
row,
that
is,
within
a
couple
of
hours?-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
e. how
many
times
did
you
use
marijuana?-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
f. how
many
times
did
you
use
any
form
of
cocaine,
including
powder,
crack,
or
freebase?-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
In
the
past
12
months
how
many
times:
g. were
you
in
a
physical
fight?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
h. have
you
sniffed
glue,
breathed
the
contents
of
aerosol
spray
cans,
or
inhaled
any
paints
or
sprays
to
get
high?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
i. have
you
used
heroin
(also
called
smack,
junk,
or
China
White)?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
j. have
you
used
methamphetamines
(also
called
speed,
crystal,
crank,
or
ice)?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
k. have
you
used
ecstasy
(also
called
MDMA)?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
l. have
you
taken
steroid
pills
or
shots
without
a
doctor's
prescription?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
m. have
you
used
a
needle
to
inject
any
illegal
drug
into
your
body?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
n. How
many
times
in
your
life
have
you
used
a
prescription
drug
NOT
prescribed
to
you
by
a
doctor?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
0
days
1
day
2-‐3
days
6
or
more
days
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
0
1
or
2
3
to
9
10
to
19
20
to
39
40
or
more
5. PNRC
Adolescent
Outcome
Measures
v8
5/30/2010
5
10.
Bullying
and
Victimization
How
often
do
you
….
a. call
a
student
names,
swear
at
a
student,
or
say
mean
things
to
a
student
at
school?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
b. hit,
push,
or
physically
fight
a
student
at
school?
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
c. refuse
to
talk
to
another
student? -‐-‐-‐-‐-‐-‐-‐
d. gossip
or
spread
rumors
about
another
student? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
e. encourage
others
not
to
talk
to
another
student? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
b. How
often
does…
a. a
student
hit,
push
or
physically
fight
you
at
school? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
b. A
student
call
you
names,
swear
at
you,
or
say
mean
things
to
you
at
school? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
c. A
student
refuse
to
talk
to
you? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
d. Students
gossip
or
spread
rumors
about
you? -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
e. A
student
encourage
others
not
to
talk
to
you?-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
11.
School
Safety
a.
Students
feel
safe
at
my
school………………………………………
b.
I
feel
safe
traveling
to
and
from
school………………………….
c. My
school
is
clean
and
in
good
repair…………………………….
d. At
my
school,
school
grounds
and
hallways
are
well
supervised……………………………………………………………………….
.
12. During
the
past
3
months,
with
how
many
people
did
you
have
sexual
intercourse?
A.
I
have
never
had
sexual
intercourse
B.
I
have
had
sexual
intercourse,
but
not
during
the
past
3
months
C.
1
person
D.
2
people
E.
3
people
F.
4
people
G.
5
people
H.
6
or
more
people
13. The
last
time
you
had
sexual
intercourse,
did
you
or
your
partner
use
a
condom?
……………
Never
in
the
past
month
1-‐2
times
in
the
past
month
3-‐4
times
in
the
past
month
2-‐4
times
in
the
past
WEEK
1
time
per
day
2-‐5
times
per
day
6-‐9
times
per
day
10
times
per
day
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
Strongly
Disagree
Disagree
Neither
agree
nor
disagree
Agree
Strongly
Agree
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
no
yes
I
have
never
had
sexual
intercourse
1
2
8
6. PNRC
Adolescent
Outcome
Measures
v8
5/30/2010
6
14.
Mental
Health
During
the
past
12
months:
a. 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?................................................
b. did
you
ever
seriously
consider
attempting
suicide?..............................................
c. did
you
make
a
plan
about
how
you
would
attempt
suicide?..................................
d. During
the
past
12
months,
how
many
times
did
you
actually
attempt
suicide?
e.
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.).
15.
Health
Behaviors
During
the
past
7
days,
how
many
times
…
a. did
you
eat
fruit?
(Do
not
count
fruit
juice.)
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
b. During
the
past
7
days,
how
many
times
did
you
eat
green
salad?
-‐
c. During
the
past
7
days,
how
many
times
did
you
eat
potatoes?
(Do
not
count
french
fries,
fried
potatoes,
or
potato
chips.)
-‐-‐-‐-‐-‐-‐
d. During
the
past
7
days,
how
many
times
did
you
eat
carrots?
-‐-‐-‐-‐-‐-‐-‐
e. During
the
past
7
days,
how
many
times
did
you
eat
other
vegetables?
(Do
not
count
green
salad,
potatoes,
or
carrots.)
-‐-‐-‐-‐-‐
f. 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.)
-‐-‐
no
yes
1
2
1
2
1
2
0
times
1
time
2
or
3
times
4
or
5
times
6
or
more
times
0
1
2
3
4
5
6
7
Never
1-‐3
times
4-‐6
times
Every
day
Twice
per
day
3
times
per
day
4
or
more
times
per
day
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7. PNRC
Adolescent
Outcome
Measures
v8
5/30/2010
7
16.
Health
Issues
a. Has
a
doctor
or
nurse
ever
told
you
that
you
have
asthma?
1. Yes
2. No
3. Not
sure
b. Do
you
still
have
asthma?
1. I
have
never
had
asthma
2. Yes
3. No
4. Not
sure
c. How
often
do
you
eat
breakfast?
1. Hardly
ever
2. A
few
times
a
month
3. On
weekend
mornings
4. 3-‐4
times
a
week
5. Almost
every
day
d. How
often
do
you
eat
a
meal
from
a
fast
food
restaurant?
1. Hardly
ever
2. 2-‐3
times
a
month
3. 1-‐2
times
a
week
4. 3-‐4
times
a
week
5. Almost
every
day
e. In
the
past
12
months,
have
you
suffered
any
serious
injuries?
For
example,
broken
bones,
cuts
or
lacerations,
burns,
torn
muscles,
tendons
or
ligaments,
or
other
injuries
that
interfered
with
your
ability
to
perform
daily
tasks?
1. No,
none
2. Yes,
occasionally
3. Yes,
often
f. In
the
past
12
months,
have
you
gone
to
an
Emergency
Department
because
you
were
injured?
1. No,
never
2. Yes,
once
3. Yes,
a
few
times
4. Yes,
many
times
8. PNRC
Adolescent
Outcome
Measures
v8
5/30/2010
8
g. Do
you
or
your
family
currently
have
any
type
of
health
insurance
coverage
that
pays
for
at
least
some
of
your
medical
expenses?....................................
h. In
your
neighborhood,
do
you
have
access
to:
Pharmacy
or
drug
store
…………………………………………………………………..
Clinic
or
doctor’s
office
where
you
can
go
…………………………………………
Dentist
or
dental
clinic
where
you
can
go
………………………………………….
i. What
kind
of
place
do
you
go
to
most
often
when
you
are
sick
or
you
need
medical
advice?
1. Clinic
or
Health
Center………………………………………………………………………
2. Doctor's
Office
or
HMO……………………………………………………………….......
3. Hospital
or
emergency
room………………………………………………………….....
4. Hospital
or
Outpatient
Department…………………………………………………
5. Some
other
place…………………………………………………………………………….
6. Don't
go
to
one
place
more
often………………………………………………………
j. How
long
ago
did
you
last
have
a
routine
check-‐up?
1. In
the
last
month
2. In
the
last
6
months
3. In
the
last
year
4. More
than
a
year
ago
5. Never
that
I
know
of
k.
In
the
past
12
months
have
you
had
a
dental
examination
by
a
dentist
or
dental
hygienist?
A.
No
B.
Yes
l. How
tall
are
you
in
feet
and
inches?
_______Feet,
________inches
m.
What
is
your
current
weight
in
pounds?
____________pounds.
You
are
done!
Thank
you
very
much
for
your
time.
No
Yes
Don’t
Know
1
2
3
1
2
3
1
2
3
1
2
3
No
Yes
1
2
1
2
1
2
1
2
1
2
1
2