Global School-based Student Health Survey (GSHS)

2007 Indonesia
GSHS Questionnaire

For more information:

[Link]/gshs or
[Link]/chp/gshs/en/
 2007 INDONESIA GLOBAL SCHOOL-BASED STUDENT HEALTH SURVEY

This survey is about your health and the things you do that may affect your health.
Students like you all over your country are doing this survey. Students in many other
countries around the world also are doing this survey. The information you give will be
used to develop better health programs for young people like yourself.

DO NOT write your name on this survey or the answer sheet. The answers you give
will be kept private. No one will know how you answer. Answer the questions based on
what you really know or do. There are no right or wrong answers.

Completing the survey is voluntary. Your grade or mark in this class will not be affected
whether or not you answer the questions. If you do not want to answer a question, just
leave it blank.

Make sure to read every question. Fill in the circles on your answer sheet that match
your answer. Use only the pencil you are given. When you are done, do what the
person who is giving you the survey says to do.

Here is an example of how to fill in the circles:

Fill in the circles like this Not like this or

Survey
1. Do fish live in water?
A. Yes
B. No

Answer sheet
1. A B C D E F G H

Thank you very much for your help.

Indonesia GSHS Questionnaire – 2007 2

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Last Updated: October 19, 2007
1. How old are you? The next 3 questions ask about your height,
weight, and going hungry.
A. 11 years old or younger
B. 12 years old 4. How tall are you without your shoes on? ON
C. 13 years old THE ANSWER SHEET, WRITE YOUR HEIGHT
D. 14 years old IN THE SHADED BOXES AT THE TOP OF THE
E. 15 years old GRID. THEN FILL IN THE OVAL BELOW EACH
F. 16 years old or older NUMBER.

2. What is your sex? Example

Height (cm)
A. Male
1 5 3
B. Female 0 0 0

1 1

3. In what class are you?

2 2 2

A. Kelas 7 3

B. Kelas 8 4 4

C. Kelas 9 5

6 6

7 7

8 8

9 9

9 I do not know

Indonesia GSHS Questionnaire – 2007 1

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5. How much do you weigh without your shoes on? The next 2 questions ask about foods you might
ON THE ANSWER SHEET, WRITE YOUR eat.
WEIGHT IN THE SHADED BOXES AT THE TOP
OF THE GRID. THEN FILL IN THE OVAL 7. During the past 30 days, how many times per day
BELOW EACH NUMBER. did you usually eat fruit, such as nanas, pepaya,
pisang, or semangka?
Example
Weight (kg) A. I did not eat fruit during the past 30 days
B. Less than one time per day
0 5 2
0 0
C. 1 time per day

1
D. 2 times per day
1 1

E. 3 times per day

2 2
F. 4 times per day
3
3
G. 5 or more times per day
4 4

5 8. During the past 30 days, how many times per day

6 6 did you usually eat vegetables, such as wortel,
7 7
kol, bayam, or kangkung?

8 8

A. I did not eat vegetables during the past 30

9 9
days
9
I do not know B. Less than one time per day
C. 1 time per day
D. 2 times per day
6. During the past 30 days, how often did you go E. 3 times per day
hungry because there was not enough food in F. 4 times per day
your home? G. 5 or more times per day

A. Never The next 4 questions ask about personal health

B. Rarely activities.
C. Sometimes
D. Most of the time 9. During the past 30 days, how many times per day
E. Always did you usually clean or brush your teeth?

A. I did not clean or brush my teeth during the

past 30 days
B. Less than 1 time per day
C. 1 time per day
D. 2 times per day
E. 3 times per day
F. 4 or more times per day

Indonesia GSHS Questionnaire – 2007 2

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10. During the past 30 days, how often did you wash The next question asks about physical fights. A
your hands before eating? physical fight occurs when two or more students
of about the same strength or power choose to
A. Never fight each other.
B. Rarely
C. Sometimes 14. During the past 12 months, how many times were
D. Most of the time you in a physical fight?
E. Always
A. 0 times
11. During the past 30 days, how often did you wash B. 1 time
your hands after using the toilet or latrine? C. 2 or 3 times
D. 4 or 5 times
A. Never E. 6 or 7 times
B. Rarely F. 8 or 9 times
C. Sometimes G. 10 or 11 times
D. Most of the time H. 12 or more times
E. Always
The next 5 questions ask about the most serious
12. During the past 30 days, how often did you use injury that happened to you during the past 12
soap when washing your hands? months. An injury is serious when it makes you
miss at least one full day of usual activities (such
A. Never as school, sports, or a job) or requires treatment
B. Rarely by a doctor or nurse.
C. Sometimes
D. Most of the time 15. During the past 12 months, how many times were
E. Always you seriously injured?

The next question asks about physical attacks. A A. 0 times

physical attack occurs when one or more people B. 1 time
hit or strike someone, or when one or more C. 2 or 3 times
people hurt another person with a weapon (such D. 4 or 5 times
as a stick, knife, or gun). It is not a physical attack E. 6 or 7 times
when two students of about the same strength or F. 8 or 9 times
power choose to fight each other. G. 10 or 11 times
13. During the past 12 months, how many times H. 12 or more times
were you physically attacked?

A. 0 times
B. 1 time
C. 2 or 3 times
D. 4 or 5 times
E. 6 or 7 times
F. 8 or 9 times
G. 10 or 11 times
H. 12 or more times
Indonesia GSHS Questionnaire – 2007 3
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16. During the past 12 months, what were you 19. During the past 12 months, what was the most
doing when the most serious injury happened to serious injury that happened to you?
you?
A. I was not seriously injured during the past 12
A. I was not seriously injured during the past 12 months
months B. I had a broken bone or a dislocated joint
B. Playing or training for a sport C. I had a cut, puncture, or stab wound
C. Walking or running, but not as part of playing D. I had a concussion or other head or neck
or training for a sport injury, was knocked out, or could not breathe
D. Riding a bicycle, scooter, becak, andong, or E. I had a gunshot wound
bendi F. I had a bad burn
E. Riding or driving in a car or other motor G. I lost all or part of a foot, leg, hand, or arm
vehicle H. Something else happened to me
F. Doing any paid or unpaid work, including
housework, yard work, or cooking The next 2 questions ask about bullying. Bullying
G. Nothing occurs when a student or group of students say
H. Something else or do bad and unpleasant things to another
student. It is also bullying when a student is
17. During the past 12 months, what was the major teased a lot in an unpleasant way or when a
cause of the most serious injury that happened student is left out of things on purpose. It is not
to you? bullying when two students of about the same
strength or power argue or fight or when teasing
A. I was not seriously injured during the past 12 is done in a friendly and fun way.
months
B. I was in a motor vehicle accident or hit by a 20. During the past 30 days, on how many days were
motor vehicle you bullied?
C. I fell
D. Something fell on me or hit me
E. I was fighting with someone A. 0 days
F. I was attacked, assaulted, or abused by B. 1 or 2 days
someone C. 3 to 5 days
G. I was in a fire or too near a flame or D. 6 to 9 days
something hot E. 10 to 19 days
H. Something else caused my injury F. 20 to 29 days
G. All 30 days
18. During the past 12 months, how did the most
serious injury happen to you?

A. I was not seriously injured during the past 12

months
B. I hurt myself by accident
C. Someone else hurt me by accident
D. I hurt myself on purpose
E. Someone else hurt me on purpose

Indonesia GSHS Questionnaire – 2007 4

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21. During the past 30 days, how were you bullied 24. During the past 12 months, did you ever feel so
most often? sad or hopeless almost every day for two weeks
or more in a row that you stopped doing your
A. I was not bullied during the past 30 days usual activities?
B. I was hit, kicked, pushed, shoved around, or
locked indoors A. Yes
C. I was made fun of because of my race or B. No
color
D. I was made fun of because of my religion 25. During the past 12 months, did you ever
E. I was made fun of with sexual jokes, seriously consider attempting suicide?
comments, or gestures
F. I was left out of activities on purpose or A. Yes
completely ignored B. No
G. I was made fun of because of how my body
or face looks 26. During the past 12 months, did you make a plan
H. I was bullied in some other way about how you would attempt suicide?

The next 6 questions ask about your feelings and A. Yes

friendships. B. No

22. During the past 12 months, how often have you 27. How many close friends do you have?
felt lonely?
A. 0
A. Never B. 1
B. Rarely C. 2
C. Sometimes D. 3 or more
D. Most of the time
E. Always The next 6 questions ask about cigarette and
other tobacco use.
23. During the past 12 months, how often have you
been so worried about something that you could 28. How old were you when you first tried a cigarette?
not sleep at night?
A. I have never smoked cigarettes
A. Never B. 7 years old or younger
B. Rarely C. 8 or 9 years old
C. Sometimes D. 10 or 11 years old
D. Most of the time E. 12 or 13 years old
E. Always F. 14 or 15 years old
G. 16 years old or older

Indonesia GSHS Questionnaire – 2007 5

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29. During the past 30 days, on how many days did 33. Which of your parents or guardians use any form
you smoke cigarettes? of tobacco?

A. 0 days A. Neither
B. 1 or 2 days B. My father or male guardian
C. 3 to 5 days C. My mother or female guardian
D. 6 to 9 days D. Both
E. 10 to 19 days E. I do not know
F. 20 to 29 days
G. All 30 days The next 5 questions ask about drinking alcohol.
This includes drinking bir bintang, anker bir,
anggur cap orang tua, vodka, whisky, anggur
30. During the past 30 days, on how many days did kolosom, tuak, or anggur ketan. Drinking alcohol
you use any other form of tobacco, such as sirih does not include drinking a few sips of wine for
or cerutu? religious purposes.

A. 0 days 34. During the past 30 days, on how many days did
B. 1 or 2 days you have at least one drink containing alcohol?
C. 3 to 5 days
D. 6 to 9 days A. 0 days
E. 10 to 19 days B. 1 or 2 days
F. 20 to 29 days C. 3 to 5 days
G. All 30 days D. 6 to 9 days
E. 10 to 19 days
31. During the past 12 months, have you ever tried to F. 20 to 29 days
stop smoking cigarettes? G. All 30 days

A. I have never smoked cigarettes 35. During the past 30 days, on the days you drank
B. I did not smoke cigarettes during the past 12 alcohol, how many drinks did you usually drink
months per day?
C. Yes
D. No A. I did not drink alcohol during the past 30
days
32. During the past 7 days, on how many days have B. Less than one drink
people smoked in your presence? C. 1 drink
D. 2 drinks
A. 0 days E. 3 drinks
B. 1 or 2 days F. 4 drinks
C. 3 or 4 days G. 5 or more drinks
D. 5 or 6 days
E. All 7 days

Indonesia GSHS Questionnaire – 2007 6

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Last Updated: October 19, 2007
36. During the past 30 days, how did you usually get The next 5 questions ask about sexual
the alcohol you drank? SELECT ONLY ONE intercourse.
RESPONSE.
40. Have you ever had sexual intercourse?
A. I did not drink alcohol during the past 30
days A. Yes
B. I bought it in a store, shop, or from a street B. No
vendor
C. I gave someone else money to buy it for me 41. How old were you when you had sexual
D. I got it from my friends intercourse for the first time?
E. I got it from home
F. I stole it A. I have never had sexual intercourse
G. I got it some other way B. 11 years old or younger
C. 12 years old
37. During your life, how many times did you drink so D. 13 years old
much alcohol that you were really drunk? E. 14 years old
F. 15 years old
A. 0 times G. 16 years old or older
B. 1 or 2 times
C. 3 to 9 times 42. During your life, with how many people have you
D. 10 or more times had sexual intercourse?

38. During your life, how many times have you ever A. I have never had sexual intercourse
had a hang-over, felt sick, got into trouble with B. 1 person
your family or friends, missed school, or got into C. 2 people
fights, as a result of drinking alcohol? D. 3 people
E. 4 people
A. 0 times F. 5 people
B. 1 or 2 times G. 6 or more people
C. 3 to 9 times
D. 10 or more times 43. During the past 12 months, have you had sexual
intercourse?
The next question asks about drugs.
A. Yes
39. During your life, how many times have you used B. No
drugs, such as putaw or sabu-sabu?
44. The last time you had sexual intercourse, did
A. 0 times you or your partner use a condom or kondom?
B. 1 or 2 times
C. 3 to 9 times A. I have never had sexual intercourse
D. 10 or more times B. Yes
C. No

Indonesia GSHS Questionnaire – 2007 7

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Last Updated: October 19, 2007
The next 2 questions ask about physical activity. The next question asks about the time you spend
Physical activity is any activity that increases mostly sitting when you are not in school or doing
your heart rate and makes you get out of breath homework.
some of the time. Physical activity can be done in
sports, playing with friends, or walking to school. 47. How much time do you spend during a typical or
Some examples of physical activity are running, usual day sitting and watching television, playing
fast walking, biking, dancing, football, menyapu, computer games, talking with friends, or doing
mengepel, and menyetrika. other sitting activities, such as main play station?

ADD UP ALL THE TIME YOU SPEND IN PHYSICAL A. Less than 1 hour per day
ACTIVITY EACH DAY. DO NOT INCLUDE YOUR B. 1 to 2 hours per day
PHYSICAL EDUCATION OR GYM CLASS. C. 3 to 4 hours per day
D. 5 to 6 hours per day
45. During the past 7 days, on how many days were E. 7 to 8 hours per day
you physically active for a total of at least 60 F. More than 8 hours per day
minutes per day?
The next 2 questions ask about going to and
A. 0 days coming home from school.
B. 1 day
C. 2 days 48. During the past 7 days, on how many days did
D. 3 days you walk or ride a bicycle to and from school?
E. 4 days
F. 5 days A. 0 days
G. 6 days B. 1 day
H. 7 days C. 2 days
D. 3 days
46. During a typical or usual week, on how many E. 4 days
days are you physically active for a total of at F. 5 days
least 60 minutes per day? G. 6 days
H. 7 days
A. 0 days
B. 1 day 49. During the past 7 days, how long did it usually
C. 2 days take for you to get to and from school each day?
D. 3 days ADD UP THE TIME YOU SPEND GOING TO
E. 4 days AND COMING HOME FROM SCHOOL.
F. 5 days
G. 6 days A. Less than 10 minutes per day
H. 7 days B. 10 to 19 minutes per day
C. 20 to 29 minutes per day
D. 30 to 39 minutes per day
E. 40 to 49 minutes per day
F. 50 to 59 minutes per day
G. 60 or more minutes per day

Indonesia GSHS Questionnaire – 2007 8

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The next 5 questions ask about your experiences 54. During the past 30 days, how often did your
at school and at home. parents or guardians really know what you were
doing with your free time?
50. During the past 30 days, on how many days did
you miss classes or school without permission? A. Never
B. Rarely
A. 0 days C. Sometimes
B. 1 or 2 days D. Most of the time
C. 3 to 5 days E. Always
D. 6 to 9 days
E. 10 or more days

51. During the past 30 days, how often were most of

the students in your school kind and helpful?

A. Never
B. Rarely
C. Sometimes
D. Most of the time
E. Always

52. During the past 30 days, how often did your

parents or guardians check to see if your
homework was done?

A. Never
B. Rarely
C. Sometimes
D. Most of the time
E. Always

53. During the past 30 days, how often did your

parents or guardians understand your problems
and worries?

A. Never
B. Rarely
C. Sometimes
D. Most of the time
E. Always

Indonesia GSHS Questionnaire – 2007 9

For more information: [Link]/gshs or [Link]/chp/gshs/en/
Last Updated: October 19, 2007