Form A - Healthy Youth Survey - 2012 printable pdf download

2012 Healthy Youth Survey

Form A

We are asking you to take part in this survey about issues facing students in communities in Washington.

The questions in this survey ask for your opinions about yourself, your friends, your school, and your

neighborhood or community. School, community, county, and state officials will use the information

from this survey in planning future programs to help youth.

Your answers to these questions are anonymous. This means that no one will know how you answered or

which answer sheet is yours. Do not write your name anywhere on the answer sheet.

Some of the questions are personal, such as asking about your relationships and whether you get in fights

or use drugs. Some students may find some of the questions uncomfortable or upsetting. You will be given

a list of numbers to call if you want to talk to someone about the survey or feelings it brings up.

The survey is completely voluntary. You don’t have to do this survey. You may skip any question you do

not wish to answer or stop at any time. It will not affect your grades. Other students have said this survey

is interesting and they enjoyed filling it out. We hope you will too.

Please take a minute to read the instructions below before starting the survey.

INSTRUCTIONS

1. This is not a test, so there are no right or wrong answers.

2. The questions should be answered by marking one of the answer spaces on the answer sheet. If

you don’t find an answer that fits exactly, use one that comes closest. If any question does not

apply to you, or you are not sure of what it means, just leave it blank.

3. Your answers will be read by a computer. Please follow these instructions carefully.

 Use a pencil only.

This kind of mark will work:

 Make heavy mark inside the bubbles.

Correct Mark

 Erase cleanly any answer you wish to change.

These kinds of marks will NOT work:

 Make no other markings or comments on the answer pages.

Incorrect Marks

4. Some of the questions have the following format:

Please mark in the bubble which of the four words best describes how you feel about that sentence.

EXAMPLE: Pepperoni pizza is one of my favorite foods.

In this example, the student marked yes because he or she thinks the statement is mostly true.

a. NO! – means definitely not true for you

b. no – means mostly not true for you

c. yes – means mostly true for you

d. YES! – means definitely true for you

DSHS 22-1460 (5/11)

Form A - Healthy Youth Survey - 2012