Youth Risk Behavior Survey Template Page 11
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1666.
During the past 30 days, how many
71.
During the past 30 days, how many
times have you used ecstasy (also
times have you taken over-the-
called MDMA)?
counter drugs to get high?
A.
0 times
A.
0 times
B.
1 or 2 times
B.
1 or 2 times
C.
3 to 9 times
C.
3 to 9 times
D.
10 to 19 times
D.
10 to 19 times
E.
20 to 39 times
E.
20 to 39 times
F.
40 or more times
F.
40 or more times
67.
During your life, how many times
72.
During the past 30 days, how many
have you taken steroid pills or shots
times have you taken a prescription
without a doctor's prescription?
drug (such as OxyContin, Percocet,
A.
0 times
Vicodin, Adderall, Ritalin, or Xanax)
without a doctor’s prescription?
B.
1 or 2 times
C.
3 to 9 times
A.
0 times
D.
10 to 19 times
B.
1 or 2 times
E.
20 to 39 times
C.
3 to 9 times
F.
40 or more times
D.
10 to 19 times
E.
20 to 39 times
68.
During your life, how many times
F.
40 or more times
have you used a needle to inject any
illegal drug into your body?
A.
0 times
The next 10 questions ask about sexual
B.
1 time
behavior.
C.
2 or more times
73.
Have you ever had sexual
69.
During the past 12 months, has
intercourse?
anyone offered, sold, or given you an
A.
Yes
illegal drug on school property?
B.
No
A.
Yes
B.
No
74.
How old were you when you had
sexual intercourse for the first time?
70.
During the past 12 months, how
A.
I have never had sexual
many times have you attended school
intercourse
under the influence of alcohol or
B.
11 years old or younger
other illegal drugs, such as marijuana
C.
12 years old
or cocaine?
D.
13 years old
A.
0 times
E.
14 years old
B.
1 or 2 times
F.
15 years old
C.
3 to 9 times
G.
16 years old
D.
10 to 19 times
H.
17 years old or older
E.
20 to 39 times
F.
40 or more times
-11-
2009 YRBS
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