Safe Survey 2004

On a scale of 1-5, rate the following questions when applicable

(Circle the relevant number)

( 1=Very Safe, 2= Safe, 3= Neutral, 4= Unsafe, 5= Very Unsafe )  

Age__________ Gender__________

Race/ Ethnicity __________________ Grade _______________

1. Have you ever heard of M.A.S.H. Services of the Bluegrass ?

Yes No

2. Have you ever heard of MASH Drop Inn Center?

Yes No

3. Have you ever used MASH Drop Inn?

Yes No

4. Have you ever heard of Safe Place?

Yes No

5. Have you ever used Safe Place?

Yes No

6. How safe do you feel at home?

1 2 3 4 5

7. How safe do you feel at school?

1 2 3 4 5

8. Have you ever thought about running away?

Yes No

9. Have you ever ran away?

Yes No

10. If you have ran away, why?

___ Parents do not understand me

___ Drug Use (personal or parents use)

___ Being abused (physical, mental, and/ or mental)

___ Other _________________________________

11. Are you currently living with your legal guardian?

Yes No

13. If not, who are you staying with?

___ Friends

___ Other family members

___ Live on my own

___ Do not have a place to stay

12. Have you ever been homeless?

Yes No

13. If so, why?

___ Family evicted

___ Ran away

___ Kicked out of home

___ Other ______________________________________

14. Have you ever used drugs?

Yes No

15. If so, how often?

___ Daily ___ Weekly

___ Monthly ___ Once in a While

16. If so, what kind? (mark all that apply)

___ Marijuana ___ Crack/cocaine

___ Heroin ___ Ecstasy

___ Oxy Cotin ___ Methamphetamines

___ Other_______________________________________

17. Why do you use drugs?

___ Friends use it

___ Relieves stress/ depression

___ Feels Good

___ Don’t know

___ Other _________________________________________

18. Do any of your family members use drugs?

Yes No

19. Have you ever used drugs with your family members?

Yes No

20. Do you share needles?

Yes No

21. Have you ever traded sex for drugs or money?

Yes No

22. Have you ever had sex?

Yes No

23. If so, how often?

___ Daily ___ Weekly

___ Monthly ___ Once in a While

24. How many sexual partners have you had?

___ 0-3 ___ 4-6

___ 7-8 ___ 9 or more

25. What is your sexual orientation?

___ Heterosexual

___ Homosexual

___ Bisexual

26. Why do you have sex?

___ Love ___ Friends are doing it

___ Feel like it ___ Don’t know

___ Other _____________________________________

27. When having sex do you use:

Condoms Yes No

Birth Control Pill Yes No

The Patch Yes No

The Shot Yes No

28. How often do you use condoms when having sex?

___ Everytime ___ Most of the Time

___ Some of the time ___ Never

29. Have you ever been molested?

Yes No

30. If so, by whom?

___ Parent ___ Sibling

___ Other family member ___ Boyfriend/ girlfriend

___ Stranger ___ Friend

___ Other ___________________________________

31. If so, did you report it to proper authorities?

Yes No

32. Do you drink?

Yes No

33. How often

___Daily ___ Weekly

___ Monthly ___ Once in a while

34. Do you use tobacco products?

Yes No

35. If so, how often?

___ Daily ___ Weekly

___ Monthly ___ Once in a while

36. What issues affect you the most? (mark all that apply)

___ Drugs ___ Sex

___ Alcohol ___ Peer pressure

___ Relationships ___ Abuse

___ Family ___ Career planning

___ Self image ___ Stress/ depression

___ Other ___________________________________