ࡱ> wyvg 3bjbjVV =\r<r<+)(((8`t(.vxxxxxx$%BBBRvBvBBBiZBb0B "BB BB : RAHS YAC Participant Survey Parts of this survey have been adapted from the National Center for Health Statistics National Health Interview Study Youth Behavior Survey ( 1994. This survey is meant to see how beneficial the YAC program is for youth who participate. No information gathered in this survey will be used against you or prevent you from participating in the program. Information gathered in this survey will be used only by RAHS staff for the purpose of evaluating the benefits of the YAC program. No identifying information will be used in reports about the program that uses information gathered in these surveys. This survey is divided into seven sections. For each question, please answer that question by checking the line next to the response. Please check off only one unless the question says otherwise. You do not have to answer any questions that make you feel uncomfortable. If you are uncomfortable answering a question, please skip over that question. ________________________________________________________________ SECTION 1 The first set of questions ask about your academic and vocational goals and experiences. 1. How important is school to you? __ Very important __ Important __ Somewhat important __ Neutral __ Somewhat unimportant __ Important __ Very important 2. Please check off the statements that most closely relate to your response to the abovementioned question. Check off as many that apply. __ School will get me where I am going in life. __ School will not help me with my future goals. __ School is too difficult for me. __ School is fun to me. __ School is a dangerous or otherwise unsafe place for me. __ I have more interesting things going on in my life than school. __ School is the only or one of the few places where I feel safe. __ I have problems or concerns that affect my ability to come to school/participate in school activities/complete school-related assignments. __ School makes me feel good or better about myself. 3. Are you planning to complete your high school diploma/GED program? __ Yes __ No 4. After completing your high school diploma/GED program, what would you like to do? __ Pursue a degree at a college or university __ Pursue a certificate at a trade school program __ Find employment __ Other: ________________________________________________________ 5. If you would like to pursue a degree at a college or university, what degree would you like to obtain? __ I do not plan to pursue a degree at a college or university __ Associates __ Bachelors __ Masters __ PhD __ Professional degree such as a M.D./J.D. (law school) 6. How likely do you think it is that you will obtain this degree? __Very likely __ Likely __ Somewhat likely __ Neutral __ Somewhat unlikely __ Unlikely __ Very unlikely 7. If you would like to pursue a certificate at a trade school program, how likely do you think it is that you will obtain this certificate? __ Very likely __ Likely __ Somewhat likely __ Neutral __ Somewhat unlikely __ Unlikely __ Very unlikely 8. If you would like to find employment, how likely do you think it is that you will obtain steady employment? __ Very likely __ Likely __ Somewhat likely __ Neutral __ Somewhat unlikely __ Unlikely __ Very unlikely ________________________________________________________________ SECTION 2 The next few questions ask about your engagement in acts of physical violence. 9. During the past 12 months, how many times were you in a physical fight? __ 0 times __ 1 time __ 2 or 3 times __ 4 or 5 times __ 6 or 7 times __ 8 or 9 times __ 10 or 11 times __ 12 or more times 10. The last time you were in a physical fight, with whom did you fight? __ You have never been in a physical fight __ A total stranger __ A friend or someone you know __ A boyfriend, girlfriend, or date __ A parent, brother, sister, or other family member __ Someone not listed above __ More than one of the persons listed above 11. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club? __ 0 days __ 1 day __ 2 or 3 days __ 4 or 5 days __ 6 or more days _______________________________________________________________ SECTION 3 The next few questions ask about cigarette smoking and the use of tobacco. 12. Have you ever tried cigarette smoking, even one or two puffs? __ Yes __ No 13. How old were you when you smoked a whole cigarette for the first time? __ This question does not apply to me because I have never tried smoking a whole cigarette. __ 8 years old or younger __ 9 or 10 years old __ 11 or 12 years old __ 13 or 14 years old __ 15 or 16 years old __ 17 years or older Answer the following questions ONLY if you have ever smoked a whole cigarette. If you have smoked a whole cigarette, skip to the next section. 14. Have you ever smoked cigarettes regularly, that is, at least one cigarette every day for 30 days? __ Yes __ No 15. How old were you when you first started smoking cigarettes regularly? (At least one cigarette every day for 30 days.) __ This question does not apply to me because I have not done this regularly. __ 8 years old or younger __ 9 or 10 years old __ 11 or 12 years old __ 13 or 14 years old __ 15 or 16 years old __ 17 years or older 16. As of today, do you smoke cigarettes regularly? __ Yes __ No 17. During the past 6 months, did you try to quit smoking cigarettes? __ Yes __ No ________________________________________________________________ SECTION 4 The next few questions ask about the use of alcohol. 18. Have you ever tried alcohol other than a few sips? __ Yes __ No Answer the following questions ONLY if you have ever tried alcohol other than a few sips. If you have not ever tried alcohol other than a few sips, please skip to the next section. 19. How old were you when you had your first drink of alcohol other than a few sips? __ 8 years old or younger __ 9 or 10 years old __ 11 or 12 years old __ 13 or 14 years old __ 15 or 16 years old __ 17 years or older 20. During the past 30 days, on how many days did you have at least one drink of alcohol? __ 0 days __ 1 or 2 days __ 3 to 5 days __ 6 to 9 days __ 10 to 19 days __ 20 to 29 days __ All 30 days 21. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row? (Within a couple of hours) __ This question does not apply to me because I have not done this during my life. __ 0 days __ 1 day __ 2 days __ 3 to 5 days __ 6 to 9 days __ 10 to 19 days __ 20 or more days ________________________________________________________________ SECTION 5 The next few questions ask about the use of marijuana and/or other drugs. 22. Have you ever tried any drug, including marijuana, cocaine, ecstasy, and/or other drugs? __ Yes __ No Answer the following questions ONLY if you have ever tried any drug, including marijuana, cocaine, ecstasy, and/or other drugs. If you have never tried any drug, please skip to the next section. 23. How old were you when you tried marijuana for the first time? __ This question does not apply to me because I have never done this during my life. __ 8 years old or younger __ 9 or 10 years old __ 11 or 12 years old __ 13 or 14 years old __ 15 or 16 years old __ 17 years or older 24. During your life, how many times have you used marijuana? __ This question does not apply to me because I have never done this during my life. __ 1 or 2 times __ 3 to 9 times __ 10 to 19 times __ 20 to 39 times __ 40 to 99 times __ 100 or more times 25. During the past 30 days, how many times did you use marijuana? __ This question does not apply to me because I have never done this during my life. __ 0 times __ 1 or 2 times __ 3 to 9 times __ 10 to 19 times __ 20 to 39 times __ 40 or more times 26. During your life, how many times have you used any other type of illegal drug, such as the crack or freebase forms of cocaine, LSD, PCP, ecstasy, mushrooms, speed, ice, heroin, or pills without a doctors prescription? __ This question does not apply to me because I have never done this during my life. __ 0 times __ 1 or 2 times __ 3 to 9 times __10 to 19 times __ 20 to 39 times __ 40 or more times 27. During your life, how many times have you used any other substance for the purposes of getting high? (such as inhalants) __ This question does not apply to me because I have never done this during my life. __ 1 or 2 times __ 3 to 9 times __ 10 to 19 times __ 20 to 39 times __ 40 or more times ________________________________________________________________ SECTION 6 The next few questions ask about sexual intercourse (By intercourse we mean vaginal and/or anal intercourse.) 28. Have you ever had sexual intercourse? (By intercourse we mean vaginal and/or anal intercourse.) __ Yes __ No Answer the following questions ONLY if you have ever had sexual intercourse during your life. If you have never had sexual intercourse, please skip to the last section. 29. How old were you when you had sexual intercourse for the first time? __ 11 years old or younger __ 12 years old __ 13 years old __ 14 years old __ 15 years old __ 16 years old __ 17 years or older 30. During the past 3 months, with how many people did you have sexual intercourse? __ None __ 1 person __ 2 people __ 3 people __ 4 people __ 5 people __ 6 or more people 31. Did you drink alcohol or use drugs before you had sexual intercourse the last time? __ This question does not apply to me because I have never used alcohol of used drugs before sexual intercourse during my life. __ Yes __ No 32. The last time you had sexual intercourse, did you or your partner use a method of contraception to prevent pregnancy and/or STIs, including HIV infection? __ This question does not apply to me because I have never used a method of contraception during sexual intercourse during my life. __ Yes __ No ________________________________________________________________ SECTION 7 The next few questions ask more about you. 33. How old are you? __ 13 __ 14 __ 15 __ 16 __ 17 __ 18 or older 34. What grade are you in? __ 6th __ 7th __ 8th __ 9th __ 10th __ 11th __ 12th __ I have graduated from high school diploma/GED program. 35. How would you rate your academic performance? __ Excellent __ Good __ Fair __ Poor __ I am not currently in school because I have graduated from high school. 36. What is your current GPA? __ 3.5-4.0 GPA __ 3.0-3.49 GPA __ 2.5-2.99 GPA __ 2.0-2.49 GPA __ 1.5-1.99 GPA __ 1.0-1.49 GPA __ 0.5-0.99 GPA __ below 0.49 __ I am not currently in school because I have graduated from high school. 36. Are you: __ Male __ Female __ Transgender 37. What is your racial/ethnic background? __ White/Caucasian __ Black/African American __ Hispanic, not of Latin descent __ Hispanic, of Latin descent __ Asian/Pacific Islander __ South Asian/Indian __ Native American/American Indian __ Multiracial __ I prefer not to answer 37. 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