American College Health Association: National College Health Assessment

Community Health Department, Wardenburg Health Center

American College Health Association
National College Health Assessment

Instructions:
The following questions ask about various aspects of your health. To answer the questions, fill in the oval that corresponds to your response. Select only one response unless instructed otherwise. This survey is completely voluntary. You may choose not to participate or not to answer any specific question. You may skip any question you are not comfortable in answering. This survey is completely anonymous. Composite data will be shared with Wardenburg Community Health Department for use in health promotion activities. Thank you for taking the time and thought to complete this survey. We appreciate your participation!

Instructions:

The following questions ask about various aspects of your health.

To answer the questions, fill in the oval that corresponds to your response. Select only one response unless instructed otherwise. This survey is completely voluntary. You may choose not to participate or not to answer any specific question.

You may skip any question you are not comfortable in answering. This survey is completely anonymous.

Composite data will be shared with Wardenburg Community Health Department for use in health promotion activities. Thank you for taking the time and thought to complete this survey. We appreciate your participation!

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 in the last school year? (Select all that apply.)
	Tobacco use prevention	Pregnancy prevention
	Alcohol and other drug use prevention	AIDS/ HIV
	Sexual assault/relationship violence prevention	Sexually transmitted diseases (STD) prevention
	Violence prevention	Dietary behaviors and nutrition
	Injury prevention and safety	Physical activity and fitness
	Suicide prevention	None of the above

	3. Use the scale below to record the BELIEVABILITY of each source of health information.			4. Do you usually get health-related information from any of the following sources?
(Please mark the best response for each question to the right)	Believable	Neither Believable nor Unbelievable	Not Believable	No	Yes
Leaflets, pamphlets, flyers
Campus newspaper articles
Health center medical staff
Health educators
Friends
Resident assistants/advisors
Parents
Religious center
Television
Magazines
Campus peer educators
Faculty/coursework
Internet/world wide web
Other

5. Within the last school year, how often did you:		N/A (didn't do this within the last school year)	Never	Rarely	Sometimes	Most of the time	Always
Wear a seatbelt when you rode in a car?
Wear a helmet when you rode a bicycle?
Wear a helmet when you rode a motorcycle?
Wear a helmet when you were inline skating?

6. Within the last school year, were you:	No	Yes
In a physical fight?
Physically assaulted (do not include sexual assault)?

7. Within the last school year, have you experienced:	No	Yes
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:	No	Yes
Emotionally abusive?
Physically abusive?
Sexually abusive?

Remember, if these questions are disturbing to you, you may always discontinue the survey and seek professional assistance from:
     - CU Office of Victim Assistance: 303-492-8855
     - CU Psychiatry Clinic at Wardenburg Health Center: 303-492-5654
     - CU Counseling and Career Services: 303-492-6766

The next 11 questions ask about alcohol, tobacco, and drugs.

9. Within the last 30 days, on how many days did you use:
(Mark one for each row)	Never used	Have used, but not in last 30 days	1-2 days	3-5 days	6-9 days	10-19 days	20-29 days	All 30 days
Cigarettes
Cigars
Smokeless tobacco
Alcohol (beer, wine, liquor)
Marijuana (pot, hash, hash oil)
Cocaine (crack, rock, freebase)
Amphetamines (diet pills, speed, meth, crank)
Rohypnol (roofies), GHB, or Liquid X (intentional use)
MDMA (Ecstasy, XTC, E, X, Adam)
Other drugs

10. Within the last 30 days, how often do you think the typical student at your school used: State your best estimate.
(Mark one for each row)	Never used	One or more days	Used daily
Cigarettes
Cigars
Smokeless tobacco
Alcohol (beer, wine, liquor)
Marijuana (pot, hash, hash oil)
Cocaine (crack, rock, freebase)
Amphetamines (diet pills, speed, meth, crank)
Rohypnol (roofies), GHB, or Liquid X (intentional use)
MDMA (Ecstasy, XTC, E, X, Adam)
Other drugs

One drink or alcoholic beverage is defined as a 12 oz. beer, a 4 oz. glass of wine, a shot of liquor or a mixed drink.
11. Within the last 30 days, did you:
(Mark one for each row)	Not applicable/ Don't drive	Not applicable/ Don't drink	No	Yes
Drive after drinking any alcohol at all
Drive after having 5 or more drinks

12.	The last time you "partied"/socialized, how many HOURS did you drink alcohol? State your best estimate.
		Hours

13.	The last time you "partied"/socialized, how many alcoholic DRINKS did you have? State your best estimate.
		Drinks

14.	In the last two weeks on how many occasions did you drink the same or more alcohol as indicated in item #13? State your best estimate.
		Occasions

15.	How many alcoholic DRINKS do you think the typical student at your school had the last time he or she "partied"/socialized? State your best estimate.
		Drinks

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

17. During the last school year, if you "partied"/socialized, how often did you...
(Please mark the appropriate column for each row.)	Not applicable/ Don't drink	Always	Usually	Sometimes	Rarely	Never
Alternate non-alcoholic with alcoholic beverages
Determine, in advance, not to exceed a set number of drinks
Choose not to drink alcohol
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
Drink an alcohol look-alike (non-alcoholic beer, punch etc.)

18. If you drink alcohol, within the last school year, have you experienced any of the following as a consequence of your drinking?
(Please mark the appropriate column for each row.)	Not applicable/ Don't drink	No	Yes
Physically injured yourself
Physically injured another person
Been involved in a fight
Did something you later regretted
Forgot where you were or what you did
Had someone use force or threat of force to have sex with you
Had unprotected sex

19. Within the last 30 days, what percent of students at your school: State your best estimate.

Used Cigarettes (%)	Used Alcohol (%)	Used Rohypnol or GHB (%)

The next 11 questions ask about sex behavior, perceptions, and contraception.

20.	Within the last school year, with how many partners, if any, have you had sex (oral, vaginal, or anal)?
		Number Partners

21. Within the last school year, were your sexual partner(s), if any ...
	N/A	Female	Male	Both Male and Female

22.	Within the last school year, with how many partners do you think the typical student at your school has had sex (oral, vaginal, or anal)?
		Number Partners

Please mark the appropriate column for each row in questions 23 through 27.

23. Within the last 30 days, if you are sexually active, how many times did you have:
	Never did this sexual activity	Have not done this during last 30 days	1-2 times	3-4 times	5-6 times	7-8 times	9-10 times	11 or more times
Oral sex?
Vaginal intercourse?
Anal intercourse?

24. How many times within the last 30 days do you think the typical student at your school has had:
	0 times	1-2 times	3-4 times	5-6 times	7-8 times	9-10 times	11 or more times
Oral sex?
Vaginal intercourse?
Anal intercourse?

25. Within the last 30 days, if you are sexually active, how often did you or your partner(s) use a condom during:
	Never did this sexual activity	Have not done in this during last 30 days	CONDOM USE
	Never did this sexual activity	Have not done in this during last 30 days	Never	Rarely	Sometimes	Mostly	Always
Oral sex?
Vaginal intercourse?
Anal intercourse?

26. Within the last 30 days, how often do you think the typical student at your school has used a condom during:
	The typical student at my school does not participate in this kind of sexual activity	CONDOM USE
		Never	Rarely	Sometimes	Mostly	Always
Oral sex?
Vaginal intercourse?
Anal intercourse?

27. If you are sexually active, did you use a condom the last time you had:
	Never did this sexual activity	No	Yes	Don't know/ Don't remember
Oral sex?
Vaginal intercourse?
Anal intercourse?

28. If you have had vaginal intercourse, what method did you or your partner use to prevent pregnancy the last time? (Select all that apply)
	Have not had vaginal intercourse	Spermicide (e.g. foam)
	Birth control pills	Fertility awareness (calendar, mucous, basal body temperature)
	Depo Provera (shots)	Withdrawal
	Norplant (implant)	Other method
	Condoms (male or female)	Nothing
	Diaphragm/ Cervical cap/ Sponge

29. Within the last school year, if you are sexually active, have you or your partner(s) used emergency contraception ("morning after pill")?
	No	Yes	Don't know	Not sexually active

30. Within the last school year, have you unintentionally become pregnant or gotten someone else pregnant?
	Have not had vaginal intercourse within the last school year	No	Yes	Don't know

The next 5 questions ask about weight, nutrition and exercise

31. How do you describe your weight?
	Very underweight Slightly underweight About the right weight Slightly overweight Very overweight
32. Are you trying to do any of the following about your weight?
	I am not trying to do anything about my weight Stay the same weight Lose weight Gain weight
33. Within the last 30 days, did you do any of the following? (Select all that apply.)
	Exercise to lose weight Diet to lose weight Vomit or take laxatives to lose weight Take diet pills to lose weight I didn't do any of the above
34. How many servings of fruits and vegetables do you usually have per day? (1 serving=1 medium piece of fruit,1/2 cup chopped, cooked, or canned fruits/vegetables, 3/4 cup fruit/vegetable juice, small bowl of salad greens, or 1/2 cup dried fruit)
	I don't eat fruits and vegetables 1-2 3-4 5 or more

35. On how many of the past 7 days did you:
(Please mark the appropriate column for each row.)	0 days	1 day	2 days	3 days	4 days	5 days	6 days	7 days
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 weight lifting?
Get enough sleep so that you felt rested when you woke up in the morning?

The next 6 questions ask about mental and physical health

36. Within the last school year how many times have you:
(Please mark the appropriate column for each row.)	Never	1-2 times	3-4 times	5-6 times	7-8 times	9-10 times	11 or more times
Felt things were hopeless
Felt overwhelmed by all you had to do
Felt exhausted (not from physical activity)
Felt very sad
Felt so depressed that it was difficult to function
Seriously considered attempting suicide
Attempted suicide

37. Have you ever been diagnosed with depression?
	Yes	No
	If you responded "No", please go to question 38.

		No	Yes
If Yes:	Have you been diagnosed with depression within the last school year?
	Are you currently in therapy for depression?
	Are you currently taking medication for depression?

38. Have you:
(Please mark the appropriate column for each row.)	No	Yes	Don't Know
Been vaccinated against hepatitis B?
Been vaccinated against meningococcal disease (meningococcal meningitis)?
Been vaccinated against varicella (chicken pox)?
Been vaccinated with measles, mumps, rubella (2 shots)?
Been vaccinated against influenza (the flu) in the last year?
Had a dental exam and cleaning in the last year?
(Males) Performed testicular self exam in the last month?
(Females) Performed breast self exam in the last month?
(Females) Had a routine gynecological exam in the last year?
Had your blood pressure checked in the last 2 years?
Had your cholesterol checked in the last 5 years?
Used sunscreen daily?

39. Have you ever been tested for HIV infection?
	No	Yes	Don't know

40. Please make a Yes/No selection for each of the following pairs of columns.
	Within the last school year, have you had any of the following?		Have you ever been diagnosed with any of the following?
	No	Yes	No	Yes
Allergy problems
Anorexia
Anxiety Disorder
Asthma
Bulimia
Chronic Fatigue Syndrome
Depression
Diabetes
Endometriosis
Genital herpes
Genital warts/HPV
Hepatitis B or C
High blood pressure
High cholesterol
HIV infection
Repetitive stress injury (e.g. carpal tunnel syndrome)
Seasonal Affective Disorder
Substance abuse problem
Back pain
Broken bone/fracture
Bronchitis
Chlamydia
Ear infection
Gonorrhea
Mononucleosis
Pelvic Inflammatory Disease
Sinus infection
Strep throat
Tuberculosis

41. Within the last school year have any of the following affected your academic performance?
(Please select the most serious outcome for each item below.)	This did not happen to me/ not applicable	I have experienced this issue but my academics have not been affected	Received a lower grade on an exam or important project	Received a lower grade in the course	Received an incomplete or dropped the course
Alcohol use
Allergies
Assault (physical)
Assault (sexual)
Attention Deficit Disorder
Cold/Flu/Sore throat
Concern for a troubled friend or family member
Chronic illness (diabetes, asthma, etc.)
Chronic pain
Death of a friend or family member
Depression/ Anxiety Disorder/ Seasonal Affective Disorder
Drug use
Eating disorder/problem
HIV infection
Injury
Internet use/computer games
Learning disability
Mononucleosis
Pregnancy (yours or your partner's)
Relationship difficulty
Sexually transmitted disease
Sinus infection/ ear infection/ bronchitis/ strep throat
Sleep difficulties
Stress
Other

The last questions ask about demographic characteristics

42.	How old are you?
		Years

43.	What is your sex?
		Female Male

44.	What is your height in feet and inches?
		Feet Inches

45.	What is your weight in pounds?
		Pounds

46. Year in school:
	1st year undergraduate 2nd year undergraduate 3rd year undergraduate 4th year undergraduate 5th year or more undergraduate Graduate or professional Adult special Other

47. Are you a full-time student?
	Yes	No

48. How do you usually describe yourself? (Mark all that apply)
	White-not Hispanic (includes Middle Eastern) Black-not Hispanic Hispanic or Latino Asian or Pacific Islander American Indian or Alaskan Native Other

49. Are you an international student?
	Yes	No

50. What is your current relationship status?
	Single Married/domestic partner Engaged or committed dating relationship Separated Divorced Widowed

51. Which of the following best describes you?
	Heterosexual	Gay/Lesbian	Bisexual	Transgendered	Unsure

52. Where do you currently live?
	Campus residence hall Fraternity or Sorority house Other university/college housing Off-campus housing Parent/guardian's home Other

53. Are you a member of a social fraternity or sorority? (National Interfraternity Conference, National Panhellenic Conference, or National Pan-Hellenic Council)
	Yes	No

54. How many hours a week do you work for pay?
	0 hours 1-9 hours 10-19 hours 20-29 hours 30-39 hours 40 hours more than 40 hours

55. If you have a credit card(s) how much total credit card debt did you carry last month? That is, what was the total unpaid balance on all of your credit cards (that you are responsible for paying)?
None, I don't have any credit cards/ I'm not responsible for paying None, I pay the full amount each month		$1 - $99 $100 - $249 $250 - $499 $500 - $999 $1,000 - $1,999		$2,000 - $2,999 $3,000 - $3,999 $4,000 - $4,999 $5,000 - $5,999 $6,000 or more

56. What is your approximate cumulative grade average?
	A B C D/F N/A

57. How many hours a week do you volunteer?
	0 hours 1-9 hours 10-19 hours 20-29 hours 30-39 hours 40 hours more than 40 hours

58. Do you have any kind of health insurance (including prepaid plans such as HMOs-health maintenance organizations)?
	Yes	No	Not Sure

Thank you for completing this survey!

After submitting the survey, you should get an acknowledgement screen. If you do not see that screen, please try submitting your form again to make sure we get your response. If your form does not submit right away (due to lots of users on the campus web server, or a problematic modem connection), keep trying to submit your form every 5 minutes or so. If you still have difficulty, contact Cathy Kerry at cathy.kerry@colorado.edu.