Youth Risk Behavior Questionnaire Template Page 5
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
1426.
During the past 12 months, how
31.
During the past 12 months, how
frequently has someone stolen or
many times did you actually attempt
deliberately damaged your property
suicide?
such as your car, clothing, or books
A.
0 times
on school property?
B.
1 time
A.
Never
C.
2 or 3 times
B.
Once or twice
D.
4 or 5 times
C.
Monthly
E.
6 or more times
D.
Weekly
E.
Daily
32.
If you attempted suicide during the
past 12 months, did any attempt
The next question asks about hurting
result in an injury, poisoning, or
yourself on purpose.
overdose that had to be treated by a
doctor or nurse?
27.
During the past 12 months, how
A.
I did not attempt suicide
many times did you do something to
during the past 12 months
purposely hurt yourself without
B.
Yes
wanting to die, such as cutting or
C.
No
burning yourself on purpose?
A.
0 times
The next 13 questions ask about tobacco
B.
1 time
use.
C.
2 or 3 times
D.
4 or 5 times
33.
Have you ever tried cigarette
E.
6 or more times
smoking, even one or two puffs?
A.
Yes
The next 5 questions ask about sad
B.
No
feelings and attempted suicide. Sometimes
34.
How old were you when you smoked
people feel so depressed about the future
that they may consider attempting
a whole cigarette for the first time?
suicide, that is, taking some action to end
A.
I have never smoked a whole
their own life.
cigarette
B.
8 years old or younger
28.
During the past 12 months, did you
C.
9 or 10 years old
ever feel so sad or hopeless almost
D.
11 or 12 years old
every day for two weeks or more in
E.
13 or 14 years old
a row that you stopped doing some
F.
15 or 16 years old
usual activities?
G.
17 years old or older
A.
Yes
B.
No
35.
During the past 30 days, on how
many days did you smoke cigarettes?
29.
During the past 12 months, did you
A.
0 days
ever seriously consider attempting
B.
1 or 2 days
suicide?
C.
3 to 5 days
A.
Yes
D.
6 to 9 days
B.
No
E.
10 to 19 days
F.
20 to 29 days
30.
During the past 12 months, did you
G.
All 30 days
make a plan about how you would
attempt suicide?
A.
Yes
B.
No
5
2015 Arizona HS YRBS
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life