Académique Documents
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Instructions:
To answer the questions, fill in the oval that corresponds to your response.
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Use a No. 2 pencil or blue or black ink pen only. Do not use pens with ink
that soaks through the paper. CORRECT: INCORRECT: ✓ ✗
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This survey is completely voluntary. You may choose not to participate or
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not to answer any specific question. You may skip any question you are not
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comfortable in answering.
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This survey is completely anonymous. Please make no marks of any kind
on the survey which could identify you individually.
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Composite data will then be shared with your campus for use in health
promotion activities.
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PAGE ONE
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Mark Reflex® forms by NCS Pearson EM-247487-1:654321 Printed in U.S.A.
The first 8 questions ask about health, health education, and safety.
1. Considering your age, how would you describe your general health?
Excellent Very good Good Fair Poor Don't know
2. On which of the following health topics have you ever received information from your college or university?
(Select all that apply)
Tobacco use prevention Pregnancy prevention
Alcohol and other drug use prevention AIDS or HIV infection prevention
Sexual assault/relationship violence prevention Sexually transmitted disease (STD) prevention
Violence prevention Dietary behaviors and nutrition
Injury prevention and safety Physical activity and fitness
Suicide prevention None of the above
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for each question to the right) No Yes
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Resident assistants/advisors
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Parents
Religious center
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Television
Magazines
Campus peer educators
Faculty/coursework
A
Internet/world wide web
Other: (please specify)
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Always
Most of the time
Sometimes
5. Within the last school year, how often did you:
Rarely
(Please mark the appropriate Never
column for each row) N/A didn't do this within the last school year
Yes
6. Within the last school year, were you: No
In a physical fight?
Physically assaulted (do not include sexual assault)?
PAGE TWO
Yes
7. Within the last school year, have you experienced: No
Verbal threats for sex against your will?
Sexual touching against your will?
Attempted sexual penetration (vaginal, anal, oral intercourse) against your will?
Sexual penetration (vaginal, anal, oral intercourse) against your will?
8. Within the last school year, have you been in a relationship that was:
Emotionally abusive?
Physically abusive?
Sexually abusive?
Cigarettes
Cigars
Smokeless tobacco
Alcohol (beer, wine, liquor)
Marijuana (pot, hash, hash oil)
Cocaine (crack, rock, freebase)
Amphetamines (diet pills, speed, meth, crank)
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Rohypnol (roofies), GHB or Liquid X (intentional use)
Other drugs
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Never used Never used
(Mark one for each row)
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12. The last time you "partied"/socialized, H 13. The last time you "partied"/socialized, D
how many hours did you drink alcohol? O how many alcoholic drinks did you R
0 0 0 0
State your best estimate. (If less than U have? State your best estimate. (If I
1 1 1 1
10, code answers as 00, 01, 02, etc.) R less than 10, code answers as 00, 01, N
2 2 2 2
S 02, etc.) K
3 3 3 3
S
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9
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14. In the last two weeks, on how many T 15. How many alcoholic drinks do you D
occasions did you drink the same or I think the typical student at your R
0 0 0 0
more alcohol as indicated in item #13? M school had the last time he/she I
1 1 1 1
State your best estimate. (If less than 10, E "partied"/socialized? (If less than 10, N
2 2 2 2
code answers as 00, 01, 02, etc.) S code answers as 00, 01, 02, etc.) K
3 3 3 3
S
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9
16. Think back over the last two weeks. How many times, if any, have you had five or more alcoholic drinks at a sitting?
None 2 times 4 times 6 times 8 times
1 time 3 times 5 times 7 times 9 or more times
(Please mark the appropriate column for each row) Usually Sometimes
17. During the last school year, if you Always Rarely
"partied"/socialized, how often did you... Not applicable/Don't drink Never
Alternate non-alcoholic with alcoholic beverages
Determine, in advance, not to exceed a set number of drinks
Choose not to drink alcohol
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Use a designated driver
Eat before and/or during drinking
Have a friend let you know when you've had enough
Keep track of how many drinks you were having
Pace your drinks to 1 or fewer per hour
Avoid drinking games
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Drink an alcohol look-alike (non-alcoholic beer, punch etc.)
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Yes
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(Please mark the appropriate column for each row)
No
18. If you drink alcohol, within the last school year, have you experienced
Not applicable/Don't drink
any of the following as a consequence of your drinking?
19. Within the last 30 days, what percent of students at your school used? State your best estimate.
% Used % Used % Used
Cigarettes Alcohol Rohypnol or GHB
0 0 0 0 0 0
1 1 1 1 1 1
2 2 2 2 2 2
3 3 3 3 3 3
4 4 4 4 4 4
5 5 5 5 5 5
6 6 6 6 6 6
7 7 7 7 7 7
8 8 8 8 8 8
9 9 9 9 9 9
PAGE FOUR
The next 11 questions ask about sex behavior, perceptions, and contraception.
20. Within the last school year, with P P
22. Within the last school year, with how
how many partners, if any, have A A
0 0 many partners do you think the typical 0 0
you had sex (oral, vaginal, or R R
1 1 student at your school has had sex 1 1
anal)? (If less than 10, code T T
2 2 (oral, vaginal, or anal)? (If less than 10, 2 2
answers as 00, 01, 02, etc.) N N
3 3 code answers as 00, 01, 02, etc.) 3 3
E E
4 4 4 4
R R
5 5 5 5
S S
21. Within last school year, were 6 6 6 6
N/A Female 8 8 8 8
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Vaginal Intercourse?
Anal Intercourse?
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24. How many times within the last 30 days do you think 1-2 times 11 or more times
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0 times
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Oral sex?
Vaginal Intercourse?
Anal Intercourse?
Oral sex?
Vaginal Intercourse?
Anal Intercourse?
PAGE FIVE
(Please mark the appropriate column for each row) No Yes
27. If you are sexually active, did you use a Never did this sexual activity Don't know/Don't remember
condom the last time you had:
Oral sex?
Vaginal Intercourse?
Anal Intercourse?
28. If you have had vaginal intercourse, what 34. What is your approximate cumulative grade average?
method did you or your partner use to prevent
pregnancy the last time? (Select all that apply) A B C D/F N/A
Have not had vaginal Spermicide (e.g. foam)
intercourse Fertility awareness
Birth control pills (calendar, mucous, The next 5 questions ask about weight,
Depo Provera (shots) basal body temperature) nutrition, and exercise.
Norplant (implant) Withdrawal
Condoms (male or female) Other method 35. How do you describe your weight?
Diaphragm/Cervical Nothing Very underweight Slightly overweight
cap/Sponge Slightly underweight Very overweight
29. Within the last school year, if you are sexually active, About the right weight
have you or your partner(s) used emergency
contraception ("morning after pill")? 36. Are you trying to do any of the following about
No Yes Don't know Not sexually active your weight?
I am not trying to do anything Lose weight
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30. Within the last school year, have you unintentionally about my weight Gain weight
become pregnant or gotten someone else pregnant? Stay the same weight
Have not had vaginal No
intercourse within the last Yes 37. Within the last 30 days, did you do any of the
school year. Don't know following? (Select all that apply)
Exercise to lose weight
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31. Have you ever been tested for HIV infection?
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Diet to lose weight
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No Yes Don't know Vomit or take laxatives to lose weight
Take diet pills to lose weight
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32. Which of the following best describes you? I didn't do any of the above
Heterosexual Bisexual Unsure
Gay/Lesbian Transgendered
38. How many servings of fruits and vegetables do
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33. If you have a credit card(s) how much total credit card you usually have per day (1 serving = 1 medium
debt did you carry last month? That is, what was the total piece of fruit, 1/2 cup chopped, cooked or canned
unpaid balance on all of your credit cards (that you are fruits/vegetables, 3/4 cup fruit/vegetable juice,
responsible for paying)? small bowl of salad greens, or 1/2 cup dried fruit)?
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None, I don't have any $1 - $99 $2,000 - $2,999 I don't eat fruits and vegetables
credit cards/I'm not $100 - $249 $3,000 - $3,999 1-2
responsible for paying $250 - $499 $4,000 - $4,999 3-4
None, I pay the full $500 - $999 $5,000 - $5,999 5 or more
amount each month $1,000 - $1,999 $6,000 or more
3 days 4 days
2 days 5 days
1 day 6 days
(Please mark the appropriate column for each row) 0 days 7 days
39. On how many of the past 7 days did you:
Participate in vigorous exercise for at least 20 minutes or moderate exercise
for at least 30 minutes?
Do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or
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weight lifting?
Get enough sleep so that you felt rested when you woke up in the morning?
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The next 4 questions ask about mental and physical health.
(Please mark the appropriate column for each row) 5-6 times 7-8 times
3-4 times 9-10 times
40. Within the last school year 1-2 times 11 or more times
how many times have you: Never
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column for each row) Yes Yes
No No
42. Have you:
Been vaccinated against hepatitis B? (Females) Performed breast self exam
Been vaccinated against meningococcal disease in the last month?
(meningococcal meningitis)? (Females) Had a routine gynecological
Been vaccinated against varicella (chicken pox)? exam in the last year?
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Been vaccinated with measles, mumps, rubella Had your blood pressure checked in
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Have you ever been diagnosed Yes Have you ever been diagnosed Yes
with any of the following? No with any of the following? No
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Within the last school year, Yes Within the last school year, Yes
have you had any of the following? No have you had any of the following? No
43. (Please make two marks in the
appropriate columns for each row)
Allergy problems Repetitive stress injury
Anorexia (e.g. carpal tunnel syndrome)
Anxiety Disorder Seasonal Affective Disorder
Asthma Substance abuse problem
Bulimia Back pain
Chronic Fatigue Syndrome Broken bone/fracture
Depression Bronchitis
Diabetes Chlamydia
Endometriosis Ear infection
Genital herpes Gonorrhea
Genital warts/HPV Mononucleosis
Hepatitis B or C Pelvic Inflammatory Disease
High blood pressure Sinus infection
High cholesterol Strep throat
HIV infection Tuberculosis
PAGE SEVEN
The next question asks about impediments 48. What is your weight in pounds?
to academic performance. W Pounds
Received an incomplete or dropped the course 49. Year in school: E
I
Received a lower grade in the course 1st year undergraduate G
0 0 0
This did not happen to me/not applicable 5th year or more undergraduate 4 4 4
44. Within the last school year, have any Graduate or professional 5 5 5
Allergies Yes No
Assault (physical)
Assault (sexual) 51. How do you usually describe yourself? (Mark all that apply)
Attention Deficit Disorder White - not Hispanic (includes Middle Eastern)
Cold/Flu/Sore throat Black - not Hispanic
Concern for a troubled friend or Hispanic or Latino
family member Asian or Pacific Islander
Chronic illness (diabetes, asthma, etc.) American Indian or Alaskan Native
Chronic pain Other
Death of a friend or family member
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Depression/Anxiety Disorder/ 52. Are you an international student? Yes No
Seasonal Affective Disorder
Drug use 53. What is your current relationship status?
Eating disorder/problem Single Separated
HIV Infection Married/domestic partner Divorced
Injury Engaged or committed dating Widowed
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Internet use/computer games relationship
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Learning disability
Mononucleosis 54. Where do you currently live?
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Pregnancy (yours or your partner's) Campus residence hall Off-campus housing
Relationship difficulty Fraternity or sorority house Parent/guardian's
Sexually transmitted disease Other university/college home
Sinus infection/ear housing Other
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infection/bronchitis/strep throat
Sleep difficulties 55. Are you a member of a social fraternity or sorority?
Stress (National Interfraternity Conference, National Panhellenic
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7 7 9 9 prepaid plans such as HMOs - health maintenance
8 8 organizations)?
9 9 Yes No Not sure
PAGE EIGHT THANK YOU FOR COMPLETING THIS SURVEY
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