Youth Risk Behavior Survey
Help us understand youth health and safety by answering the following questions honestly. Your responses are confidential.
Participant Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Grade/Year in School
*
Please Select
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Not in school
During the past 30 days, on how many days did you smoke cigarettes?
*
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
During the past 30 days, on how many days did you have at least one drink of alcohol?
*
0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days
In the past 7 days, how many days did you eat at least one serving of fruits and vegetables?
*
0 days
1-2 days
3-4 days
5 or more days
During the past 7 days, how many days were you physically active for at least 60 minutes per day?
*
0 days
1-2 days
3-4 days
5-6 days
All 7 days
In the past 12 months, did you ever seriously consider attempting suicide?
*
Yes
No
How often do you wear a seatbelt when riding in a car driven by someone else?
*
Never
Rarely
Sometimes
Most of the time
Always
Please indicate how strongly you agree or disagree with the following statements about your school experience.
*
Rows
Strongly Disagree
Disagree
Agree
Strongly Agree
I feel safe at school.
1
2
3
4
I feel connected to my teachers.
5
6
7
8
I have friends at school.
9
10
11
12
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