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* 1. How old are you?

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* 2. What is your sex?

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* 3. In what grade are you?

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* 4. How do you describe yourself? (Select one or more)

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

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* 6. Is there at least one teacher or other adult in this school that you can talk to if you have a problem?

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* 7. Within school who is the person you would most likely go to with a problem?

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* 8. Outside of school, is there an adult (or adults) you can talk to about things that are important to you?

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* 9. The following questions ask about personal safety:

How often do you wear a seat belt when riding in a car driven by someone else?

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* 10. During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol?

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* 11. When you ride a bicycle, how often do you wear a helmet?

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* 12. When you longboard, rollerblade or ride a skateboard, how often do you wear a helmet?

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