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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.
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	
  
:	
  
:	
  
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	
  
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	
  
	
   	
   	
   	
   	
   	
  
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	
  
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	
  
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	
  
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	
  

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Pnrc adolescent survey v8 2

  • 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