Directions:  This survey is vital to helping improve future health and prevention programs for youth.  Your answers are secret.  Answer all questions honestly.  Thank you.

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* 1. What is today's date?

Date

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* 2. Create a personal code number by including the first two letters of where you were born (village, town or city) followed by the last 4 digits of your mobile phone number (e.g., ch3021).

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* 3. School or location code (Optional):

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* 4. Are you...

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* 5. How old are you?

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* 6. What is your race?

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* 7. In the next year, how likely are you to get physical activity most days a week?

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* 8. In the next year, how likely are you to get 8 or more hours of sleep most nights a week?

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* 9. In the next year, how likely are you to eat fruits and vegetables most days a week?

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* 10. In the next year, how likely are you to eat a healthy breakfast most days a week?

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* 11. In the next year, how likely are you to take a drink of alcohol?

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* 12. In the next year, how likely are you to puff on a cigarette?

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* 13. In the next year, how likely are you to try any marijuana?

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* 14. In the next year, how likely are you to try an e-cigarette?

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* 15. In the next year, how likely are you to practice a stress control or relaxation technique most days a week?

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* 16. In the next year, how likely are you to try any opioids for nonmedical reasons?

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* 17. In the next year, how likely are you to set goals to improve your health or fitness?

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* 18. If you were to drink alcohol often, would it harm your health or healthy habits?

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* 19. If you were to smoke cigarettes often, would they harm your health or healthy habits?

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* 20. If you were to use marijuana often, would it harm your health or healthy habits?

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* 21. If you were to use e-cigarettes often, would they harm your health or healthy habits?

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* 22. If you were to use opioids often,  would they harm your health or healthy habits?

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* 23. How many people your age currently drink alcohol?

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* 24. How many people your age currently smoke cigarettes?

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* 25. How many people your age currently use marijuana?

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* 26. How many people your age currently vape e-cigarettes?

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* 27. How many people your age currently use opioids for nonmedical reasons?

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