C ommunities That Care Youth Survey

This survey is voluntary. That means you do not have to take it. If you choose to take it,
you may skip any question you dont want to answer.

Thank you for agreeing to participate in this survey. The survey asks your opinion about a number of
things in your life, including your friends, your family, your neighborhood and your community. Your
answers to these questions will be confidential. That means no one will know your answers. To help us
keep your answers secret, please do not write your name on this survey form.

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4. Some of the questions have the following format:
Please fill in the circle for the word that best describes how you feel.
NO! no yes YES!
Admin code
EXAMPLE: Pepperoni pizza is one of my favorite foods.

Mark the Big NO! if you think the statement is definitely not true for you. 0 0 0 0 0

Mark the little no if you think the statement is mostly not true for you. 1 1 1 1 1

Mark the little yes if you think the statement is mostly true for you. 2 2 2 2 2

Mark the Big YES! if you think the statement is definitely true for you. 3 3 3 3 3
4 4 4 4 4
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SERIAL #
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These questions ask for some general This section asks about your experiences
information about you. Please mark the at school.
response that best describes you.
Putting them all together, what were your
How old are you? grades like last year?
10 Mostly Fs
11 Mostly Ds
12 Mostly Cs
13 Mostly Bs
14 Mostly As
15
16 During the LAST FOUR WEEKS, how many whole
17 days have you missed because you skipped or cut?
18 None
19 or older 1
2
3
What grade are you in? 4-5
6th 6-10
7th 11 or more
8th
9th How often do you feel that the schoolwork you
10th are assigned is meaningful and important?
11th Almost always
12th Often
Sometimes
Seldom
Are you: Never
Female
Male How interesting are most of your courses to you?
Very interesting and stimulating
Quite interesting
What do you consider yourself to be? Fairly interesting
(choose all that apply) Slightly dull
White Very dull
Black or African American
American Indian/Native American, Eskimo or Aleut How important do you think the things you are
Spanish/Hispanic/Latino learning in school are going to be for your later
Asian or Pacific Islander life?
Other (Please specify: _____________________________) Very important
Quite important
What is the language you use most often at home? Fairly important
English Slightly important
Spanish Not at all important
Another language (Please specify:____________________)

PLEASE DO NOT WRITE IN THIS AREA

2
 Almost always
Often These questions ask about your
Sometimes feelings and experiences in other parts
Seldom of your life.
Never
4
Now, thinking back over the past 3
year in school, how often did you: 2
1
Enjoy being in school? None

Think of your four best friends

Hate being in school?
(the friends you feel closest to).
In the past year (12 months), how
Try to do your best work in
many of your best friends have:
school?
Smoked cigarettes?

YES! Tried beer, wine or hard liquor

yes (for example, vodka, whiskey or
no gin) when their parents didnt
NO! know about it?

In my school, students have lots of Used marijuana?

chances to help decide things like
class activities and rules. Used LSD, cocaine, amphet-
amines, or other illegal drugs?
Teachers ask me to work on special
classroom projects. Been suspended from school?

My teacher(s) notices when I am Carried a handgun?

doing a good job and lets me know
about it. Sold illegal drugs?

There are lots of chances for students Stolen or tried to steal a motor
in my school to get involved in sports, vehicle such as a car or
clubs, and other school activities motorcycle?
outside of class.
Been arrested?
There are lots of chances for students
in my school to talk with a teacher Dropped out of school?
one-on-one.
Been members of a gang?
I feel safe at my school.
Very good chance
The school lets my parents know Pretty good chance
when I have done something well. Some chance
Little chance
My teachers praise me when I work No or very little chance
hard in school.
What are the chances you would be
seen as cool if you:
Are your school grades better than
the grades of most students in your Smoked cigarettes?
class?
Began drinking alcoholic
I have lots of chances to be part of beverages regularly, that is, at
class discussions or activities. least once or twice a month?

Smoked marijuana?

Carried a handgun?

3
 40 or more occasions
The next section asks about your 20 to 39 occasions
experience with tobacco, alcohol, and 10 to 19 occasions
other drugs. It also asks some other 6 to 9 occasions
personal questions. Remember, your 3 to 5 occasions
answers are confidential. This means 1 or 2 occasions
your answers will stay secret. 0 occasions

Have you ever used smokeless tobacco (chew, On how many occasions (if
snuff, plug, dipping tobacco, chewing tobacco)? any) have you:
Never
Once or twice Had alcoholic beverages (beer, wine or
Once in a while but not regularly hard liquor) to drinkmore than just a
Regularly in the past few sipsin your lifetime?
Regularly now

How frequently have you used smokeless Had alcoholic beverages (beer, wine or
tobacco during the past 30 days? hard liquor) to drinkmore than just a
Never few sipsduring the past 30 days?
Once or twice
Once or twice per week
About once a day Sniffed glue, breathed the contents of
More than once a day an aerosol spray can, or inhaled other
gases or sprays in order to get high in
Have you ever smoked cigarettes? your lifetime?
Never
Once or twice
Once in a while but not regularly Sniffed glue, breathed the contents of
Regularly in the past an aerosol spray can, or inhaled other
Regularly now gases or sprays in order to get high
during the past 30 days?
How frequently have you smoked cigarettes
during the past 30 days?
Not at all Used cocaine in your lifetime?
Less than one cigarette per day
One to five cigarettes per day
About one-half pack per day Used cocaine during the past 30 days?
About one pack per day
About one and one-half packs per day
Two packs or more per day Used marijuana (weed, pot) or hashish
(hash, hash oil) in your lifetime?

Used marijuana (weed, pot) or hashish

(hash, hash oil) during the past 30
days?

Used derbisol in your lifetime?

Used derbisol during the past 30 days?

Used heroin in your lifetime?

Used heroin during the past 30 days?

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 40 or more occasions 40+ times
20 to 39 occasions 30 to 39 times
10 to 19 occasions 20 to 29 times
6 to 9 occasions 10 to 19 times
3 to 5 occasions 6 to 9 times
1 or 2 occasions 3 to 5 times
0 occasions 1 or 2 times
Never

On how many occasions (if How many times in the past

any) have you: year (12 months) have you:

Used LSD (acid) or other psychedelics Been suspended from

(peyote, PCP) in your lifetime? school?

Carried a handgun?
Used LSD (acid) or other psychedelics
(peyote, PCP) during the past 30 days? Sold illegal drugs?

Stolen or tried to steal a

Used Ecstasy in your lifetime? motor vehicle such as a
car or motorcycle?

Used Ecstasy during the past 30 days? Been arrested?

Attacked someone with

Used methamphetamine (meth, the idea of seriously
crystal meth, crank) in your lifetime? hurting them?

Been drunk or high at

Used methamphetamine (meth,
school?
crystal meth, crank) during the
past 30 days?
Taken a handgun to
school?
Used prescription pain relievers, such as
Vicodin, OxyContin or Tylox, without
a doctors orders, in your lifetime? Have you ever belonged to a gang?
No
Used prescription pain relievers, such as
Yes
Vicodin, OxyContin or Tylox, without a
doctors orders, during the past 30 days? If you have ever belonged to a gang, did that
gang have a name?
Used prescription tranquilizers, such as
No
Xanax, Valium or Ambien, without
Yes
a doctors orders, in your lifetime?
I have never belonged to a gang.
Used prescription tranquilizers, such as Think back over the last two weeks. How many
Xanax, Valium or Ambien, without a times have you had five or more alcoholic
doctors orders, during the past 30 days? drinks in a row?
None
Used prescription stimulants, such as
Once
Ritalin or Adderall, without a doctors
Twice
orders, in your lifetime?
3-5 times
6-9 times
Used prescription stimulants, such as
10 or more times
Ritalin or Adderall, without a doctors
orders, during the past 30 days?

5
 How often do you attend religious services or
17 or older
activities?
16
15 Never
14 Rarely
13 1-2 times a month
12 About once a week or more
11
I like to see how much I can get away with.
10 or younger
Never have Very false
Somewhat false
How old were you when Somewhat true
you first: Very true

Smoked marijuana? YES!

yes
Smoked a cigarette, no
even just a puff? NO!

Had more than a sip or

two of beer, wine or Sometimes I think that life is not
hard liquor (for worth it.
example, vodka,
whiskey, or gin)? At times I think I am no good at all.

Began drinking All in all, I am inclined to think that

alcoholic beverages I am a failure.
regularly, that is, at
least once or twice a In the past year have you felt
month? depressed or sad MOST days, even if
you feel OK sometimes?
Got suspended from
school? It is all right to beat up people if they
start the fight.
Got arrested?
I think it is okay to take something
Carried a handgun? without asking if you can get away
with it.
Attacked someone with
the idea of seriously It is important to be honest with your
hurting them? parents, even if they become upset or
you get punished.
Belonged to a gang?
I think sometimes its okay to cheat at
school.

6
I ignore rules that get in my way.
These questions ask about how you
Very false would act in certain situations. They also
Somewhat false ask your opinion about certain things.
Somewhat true
Very true Youre looking at CDs in a music store with a
I do the opposite of what people tell me, just to friend. You look up and see her slip a CD under
get them mad. her coat. She smiles and says, Which one do you
want? Go ahead, take it while nobodys around.
Very false There is nobody in sight, no employees and no
Somewhat false other customers. What would you do now?
Somewhat true
Very true Ignore her.
Grab a CD and leave the store.
Once a week or more Tell her to put the CD back.
2 or 3 times a month Act like its a joke, and ask her to put the CD back.
About once a month
Less than once a month
Its 8:00 on a weeknight and you are about to go
Ive done it, but not in the past year
over to a friends home when your mother asks
Never
you where you are going. You say, Oh, just
going to go hang out with some friends. She
How many times have you done says, No, youll just get into trouble if you go
the following things? out. Stay home tonight. What would you do
now?
Done what feels good no
matter what. Leave the house anyway.
Explain what you are going to do with your friends, tell her
Done something dangerous when youd get home, and ask if you can go out.
because someone dared you to Not say anything and start watching TV.
do it. Get into an argument with her.

Done crazy things even if they You are visiting another part of town, and you
are a little dangerous. dont know any of the people your age there.
You are walking down the street, and some
teenager you dont know is walking toward you.
Sometimes we dont know what we will He is about your size, and as he is about to pass
do as adults, but we may have an idea. you, he deliberately bumps into you and you
Please tell me how true these almost lose your balance. What would you say or
statements may be for you. do?
Push the person back.
YES! Say Excuse me and keep on walking.
yes Say Watch where youre going and keep on walking.
no Swear at the person and walk away.
NO!

When I am an adult: You are at a party at someones house, and one

of your friends offers you a drink containing
I will smoke cigarettes. alcohol. What would you say or do?
I will drink beer, wine, or liquor. Drink it.
Tell your friend No thanks, I dont drink and suggest that
I will smoke marijuana. you and your friend go and do something else.
Just say No, thanks and walk away.
Make up a good excuse, tell your friend you had
something else to do, and leave.

7
 Not wrong at all These questions ask about the neighbor-
A little bit wrong hood and community where you live.
Wrong
Very wrong
Very easy
Sort of easy
How wrong do you think it is for Sort of hard
someone your age to: Very hard

Take a handgun to school?

If you wanted to get some beer, wine
Steal anything worth more than $5? or hard liquor (for example, vodka,
whiskey, or gin), how easy would it be
Pick a fight with someone? for you to get some?

Attack someone with the idea of If you wanted to get some cigarettes,
seriously hurting them? how easy would it be for you to get
some?
Stay away from school all day when
their parents think they are at If you wanted to get a drug like
school? cocaine, LSD, or amphetamines, how
easy would it be for you to get some?
Drink beer, wine or hard liquor (for
example, vodka, whiskey or gin) If you wanted to get some marijuana,
regularly? how easy would it be for you to get
some?
Smoke cigarettes?
If you wanted to get a handgun, how
Smoke marijuana? easy would it be for you to get one?

Use LSD, cocaine, amphetamines or

another illegal drug?
YES!
yes
Great risk no
Moderate risk NO!
Slight risk
No risk If a kid smoked marijuana in your
neighborhood, would he or she be
caught by the police?
How much do you think people risk
harming themselves (physically or in
If a kid drank some beer, wine or
other ways) if they:
hard liquor (for example, vodka,
whiskey, or gin) in your neighbor-
Smoke one or more packs of hood, would he or she be caught by
cigarettes per day? the police?

Try marijuana once or twice? If a kid carried a handgun in your

neighborhood, would he or she be
Smoke marijuana regularly? caught by the police?

Take one or two drinks of an

alcoholic beverage (beer, wine,
liquor) nearly every day?

2199543/3

8
 Not wrong at all YES!
A little bit wrong yes
Wrong no
Very wrong NO!

How wrong would most adults (over If I had to move, I would miss the
21) in your neighborhood think it was neighborhood I now live in.
for kids your age:
My neighbors notice when I am doing
To use marijuana? a good job and let me know.

To drink alcohol? I like my neighborhood.

To smoke cigarettes? There are lots of adults in my

neighborhood I could talk to about
something important.
5 or more adults
3 or 4 adults There are people in my neighborhood
2 adults who are proud of me when I do
1 adult something well.
None
I feel safe in my neighborhood.
About how many adults (over 21)
have you known personally who in
the past year have: Id like to get out of my neighborhood.

Used marijuana, crack, cocaine, There are people in my neighborhood

or other drugs? who encourage me to do my best.

Sold or dealt drugs?

Yes
Done other things that could get No
them in trouble with the police,
like stealing, selling stolen goods, Which of the following activities for
mugging or assaulting others, people your age are available in your
etc.? community?
Sports teams
Gotten drunk or high? Scouting
Boys and girls clubs
4-H clubs
Service clubs

YES!
yes
no
NO!

How much do each of the following

statements describe your
neighborhood:
Crime and/or drug selling

Fights

Lots of empty or abandoned

buildings

Lots of graffiti

9
 I dont have any brothers or sisters
The next few questions ask about your Yes
family. No

Not wrong at all Have any of your brothers or sisters

A little bit wrong
Wrong
Very wrong
How wrong do your parents feel it
would be for you to:
ever:
Drunk beer, wine or hard liquor (for
example, vodka, whiskey or gin)?
Smoked marijuana?

Drink beer, wine or hard liquor (for Smoked cigarettes?

example, vodka, whiskey or gin)
regularly? Taken a handgun to school?

Smoke cigarettes? Been suspended or expelled from

school?
Smoke marijuana?

Steal anything worth more than $5?

YES!
Draw graffiti, or write things or yes
draw pictures on buildings or other no
property (without the owners NO!
permission)?
The rules in my family are clear.
Pick a fight with someone?
People in my family often insult or
Have you changed homes in the past year? yell at each other.

No When I am not at home, one of my

Yes parents knows where I am and who I
How many times have you changed homes since am with.
kindergarten?
We argue about the same things in my
Never family over and over.
1 or 2 times
3 or 4 times If you drank some beer or wine or
5 or 6 times liquor (for example, vodka, whiskey,
7 or more times or gin) without your parents
Have you changed schools (including changing permission, would you be caught by
from elementary to middle and middle to high your parents?
school) in the past year?
My family has clear rules about
No alcohol and drug use.
Yes
How many times have you changed schools If you carried a handgun without
(including changing from elementary to middle your parents permission, would you
and middle to high school) since kindergarten? be caught by your parents?

Never If you skipped school, would you be

1 or 2 times caught by your parents?
3 or 4 times

2199542/3
5 or 6 times
7 or more times
Has anyone in your family ever had a severe
alcohol or drug problem?
No
Yes
10 .
 All the time
Often These questions ask for more
Sometimes information about your friends.
Never or almost never

My parents notice when I am doing 4 of my friends

a good job and let me know about it. 3 of my friends
2 of my friends
How often do your parents tell you 1 of my friends
theyre proud of you for something None of my friends
youve done?
Think about your four best friends
YES!
(the friends you feel closest to). In
yes
the past year (12 months), how
no
many of your best friends have:
NO!

Do you feel very close to your mother? Participated in clubs,

organizations or activities
Do you share your thoughts and at school?
feelings with your mother?
Made a commitment to stay
My parents ask me what I think drug-free?
before most family decisions affecting
me are made. Liked school?

Do you share your thoughts and Regularly attended religious

feelings with your father? services?

Do you enjoy spending time with your Tried to do well in school?

mother?

Do you enjoy spending time with your

father?

YES!
yes
no
NO!

If I had a personal problem, I could

ask my mom or dad for help.

Do you feel very close to your father?

My parents give me lots of chances to

do fun things with them.

My parents ask if Ive gotten my

homework done.

People in my family have serious

arguments.

Would your parents know if you did

not come home on time?

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on a sheet of paper or written where everyone taking
the survey can see them. In the spaces that follow,
record your answer to each additional question.

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Mark Reflex forms by NCS Pearson EM-219954-6:654321 HC08 Printed in U.S.A.

SERIAL #
500200D 9/2004 . 12