Youth Risk Behavior Survey Template Page 6
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1631.
During the past 12 months, did you
The next 15 questions ask about tobacco
make a plan about how you would
use.
attempt suicide?
A.
Yes
35.
Have you ever tried cigarette
B.
No
smoking, even one or two puffs?
A.
Yes
32.
During the past 12 months, how
B.
No
many times did you actually attempt
suicide?
36.
How old were you when you smoked
A.
0 times
a whole cigarette for the first time?
B.
1 time
A.
I have never smoked a whole
C.
2 or 3 times
cigarette
D.
4 or 5 times
B.
8 years old or younger
E.
6 or more times
C.
9 or 10 years old
D.
11 or 12 years old
33.
If you attempted suicide during the
E.
13 or 14 years old
past 12 months, did any attempt
F.
15 or 16 years old
result in an injury, poisoning, or
G.
17 years old or older
overdose that had to be treated by a
37.
During the past 30 days, on how
doctor or nurse?
A.
I did not attempt suicide
many days did you smoke cigarettes?
A.
0 days
during the past 12 months
B.
1 or 2 days
B.
Yes
C.
3 to 5 days
C.
No
D.
6 to 9 days
34.
During the past 12 months, how
E.
10 to 19 days
F.
20 to 29 days
many times did you do something to
G.
All 30 days
purposely hurt yourself without
wanting to die, such as cutting or
38.
During the past 30 days, on the days
burning yourself on purpose?
A.
0 times
you smoked, how many cigarettes
did you smoke per day?
B.
1 time
A.
I did not smoke cigarettes
C.
2 or 3 times
D.
4 or 5 times
during the past 30 days
E.
6 or more times
B.
Less than 1 cigarette per day
C.
1 cigarette per day
D.
2 to 5 cigarettes per day
E.
6 to 10 cigarettes per day
F.
11 to 20 cigarettes per day
G.
More than 20 cigarettes per
day
-6-
2009 YRBS
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life