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1. Please specify your gender.
Male
Female
2. Have you ever intentionally:
Skipped School
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once
0
1
2
3. Have you ever intentionally:
Run Away
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
4. Have you ever intentionally:
Driven a car without being legally licensed?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
5. Have you ever intentionally:
Driven a car while under the influence of alcohol or other drugs?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
6. Have you ever intentionally:
Been on probation or expelled from school?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
7. Have you ever intentionally:
Defied your parents’ authority?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
8. Have you ever intentionally:
Stolen items worth less than $2
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
9. Have you ever intentionally:
Stolen items worth from $2 to $50?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
10. Have you ever intentionally:
Stolen items worth more than $50?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
11. Have you ever intentionally:
Drank beer, wine, or liquor?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
12. Have you ever intentionally:
Smoked marijuana?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
13. Have you ever intentionally:
Used amphetamines (uppers, speed)?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
14. Have you ever intentionally:
Used cocaine?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
15. Have you ever intentionally:
Been so drunk that you couldn’t remember the next day things you did or said?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
16. Have you ever intentionally:
Cheated on an exam or class assignment?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
17. Have you ever intentionally:
Driven faster than the speed limit allowed?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
18. Have you ever intentionally:
Had sexual relations with a person of opposite sex to whom you were not married?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
19. Have you ever intentionally:
Had sexual relations with a person of same sex?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
20. Have you ever intentionally:
Been arrested?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
21. Have you ever intentionally:
Purposely damaged public property?
Circle the appropriate answer: 0 = never, 1 = one, 2 = more than once.
0
1
2
22. How would you classify the family which raised you? (circle one)
Upper-upper class
Lower-upper class
Upper-middle class
Lower-middle class
Upper-working class
Lower-working class
Upper-lower class
Lower-lower class
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