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Youth Survey

The greatness of a community is truly measured by the kind actions of its members.
-In reference to Coretta Scott King
 
We appreciate your time in completing the Community Health Assessment (CHA) survey. This survey provides valuable information from community members about their current health situations, needs, and issues that public health can then study and find ways to improve.
Directions
Please fill out survey to the best of your knowledge. If you feel uncomfortable answering any questions, please move on to the next question.
We want to assure you that your individual responses to the survey are completely private. Responses to the survey cannot be traced back to you.

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* 1. What city/town do you live?

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* 2. What is your zip code?

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* 3. How old are you?

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* 4. What is your sex?

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* 5. In what grade are you?

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* 6. Are you Hispanic or Latino?

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* 7. What is your race? (Select your response.)

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* 8. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?

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* 9. During the past 30 days, how many times have you been distracted by text, call, or social media while driving a car or other vehicle?

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* 10. During the past 30 days, how many days did you feel unsafe?

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* 11. During the past 12 months, how many times were you in a physical fight?

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* 12. During the past 12 months, have you ever been bullied in any of the following ways?

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* 13. During the past 12 months, did you ever feel sad or hopeless?

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* 14. Do you have someone to talk to when you are sad or hopeless?

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* 15. Have you ever tried a cigarette? If so, how long did you smoke?

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* 16. Have you ever tried an e-cigarette? If so, for how long?

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* 17. Have you ever drunk alcohol, if so, for how long?

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* 18. Have you ever tried drugs? If so, which ones?

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* 19. During the past 7 days, how many times did you eat fruit? (Do not count fruit juice.)

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* 20. During the past 7 days, how many times did you eat vegetables?

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* 21. During the past 7 days, how many times did you drink soda?

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* 22. During the past 7 days, on how many days did you eat a fast food meal?

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* 23. During the past 7 days, on how many days were you physically active for at least 60 minutes per day?

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* 24. Monday-Friday, how many hours do you use social media?

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* 25. On an average school day, how many hours do you watch tv?

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* 26. During the past 12 months, have you been tested for a sexually transmitted infection (STI)?

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* 27. When was the last time you saw a dentist?

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* 28. Has a doctor or nurse ever told you that you have asthma?

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* 29. Do you agree or disagree that you feel good about yourself?

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* 30. Do you feel safe and secure in your neighborhood?

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* 31. How many hours do you participate in after school or community activities, per week?

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* 32. During the past 30 days, where did you usually sleep?

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* 33. On an average week night, how many hours of sleep do you get?

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* 34. During the past 12 months, how would you describe your grades in school?

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* 35. After high school, which of the following are you most likely to do? (Select all that may apply.)

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* 36. In the past 12 months, have you lived without one or more essential utilities (i.e., water, electricity, gas) in your home?

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* 37. Have you ever gone to bed hungry in the past 12 months?

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* 38. Does anyone in your household smoke tobacco indoors?

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