1.	 What month is it?

❍ January	 ❍ February	 ❍ March	 ❍ April	 ❍ May ❍ June

❍ July	 ❍ August	 ❍ September	 ❍ October	 ❍ November	 ❍ December

2.	 How old are you?	 ❍ 5 ❍ 6 ❍ 7 ❍ 8 ❍ 9 ❍ 10 ❍ 11 ❍ 12 ❍ 13 ❍ 14

3.	 Are you a boy or a girl?	 ❍ Boy ❍ Girl

4.	 What is the color of your hair?	 ❍ Blond ❍ Red ❍ Brown ❍ Black

5.	 Does your skin burn easily in the sun?	 ❍ Yes ❍ No ❍ I don’t know

6.	 What are some of the ways you can keep your skin safe from the sun?

(Please fill in as many circles as you need to answer this question.)

❍ Eating cereal ❍ Using sunscreen ❍ Wearing a shirt and hat outside

We have a few questions we want you to answer about yourself and the sun. Thank you for

answering these questions. Please use a pencil to fill in the circle for each answer you choose.

If you want to change your answer choice, be sure to erase your first choice completely.

7.	 When do you have to use the most sun protection?

	 When the UV Index (Ultraviolet) is: ❍ 1 ❍ 5 ❍ 10 or higher ❍ I don’t know

8.	 You can get a sunburn on a cloudy day.	 ❍ True ❍ False

9.	 You only need to wear sunscreen when you are at the beach or pool.	 ❍ True ❍ False

10.	Keeping your skin safe from the sun is:	 ❍ Hard to do ❍ Not too hard, not too easy ❍ Easy to do

11.	 Some of the reasons why I do NOT wear sunscreen when I’m outside are because:

(Please fill in as many circles as you need to answer this question.)

❍ It takes too long to put on sunscreen.	 ❍ It’s hard to put sunscreen on my whole body.

❍ I forget to put on sunscreen.	 ❍ I don’t have any sunscreen.

❍ It stings my eyes.	 ❍ None of the choices above; I do wear sunscreen.

12.	 Some of the reasons why I do NOT wear a hat when I’m outside are because:

(Please fill in as many circles as you need to answer this question.)

❍ I forget to bring a hat.	 ❍ I don’t like to wear a hat.	 ❍ I don’t have a hat.

❍ It’s too hot to wear a hat.	 ❍ None of the choices above; I do wear a hat.

13.	Do you like to get a tan?	 ❍ Yes ❍ No

14.	 Do you think people look healthier with a tan?	 ❍ Yes ❍ No
15.	When you wear a bathing suit outside, what are all of the places that you put on sunscreen?

(Please fill in as many circles as you need to answer this question.)

❍ My face	 ❍ My arms	 ❍ My shoulders	 ❍ My legs	 ❍ My back

❍ My ears	 ❍ My stomach	 ❍ I don’t put it on

16.	Do you talk to your family about putting on sunscreen or wearing a hat or shirt to protect

yourself from the sun?

❍ Yes ❍ No

17. Do you talk to your friends about putting on sunscreen or wearing a hat or shirt to protect 	 	 	 yourself from the sun?	

❍ Yes ❍ No

18.	Last summer, how many days a week did you go outside between 10 AM and 4 PM?

❍ 0-1 day per week	 ❍ 2-3 days per week	 ❍ 4-5 days per week	 ❍ 6-7 days per week

19.	Last summer, how many hours a day did you spend outdoors between 10 AM and 4 PM?

❍ Less than 1 hour per day	 ❍ 1-2 hours per day	 ❍ 3-4 hours per day	 ❍ 5-6 hours per day

20.	 Last summer, how many hours a day did you spend at the beach or outdoor pool between

10 AM and 4 PM?

❍ Less than 1 hour per day	 ❍ 1-2 hours per day	 ❍ 3-4 hours per day	 ❍ 5-6 hours per day

When you were outside in the sun last summer:

21.	 Did you wear a hat	 All of the time?	 ❍

	 	 Sometimes?	 ❍

	 	 Never?	 ❍

22.	Did you wear a long	 All of the time?	 ❍

-sleeved shirt Sometimes?	 ❍ 	 	 Never?	 ❍

23.	Did you wear	 All of the time?	 ❍

sunglasses Sometimes?	 ❍

	 	 Never?	 ❍

24.	Did you wear	 All of the time?	 ❍

sunscreen Sometimes?	 ❍

	 	 Never?	 ❍

	 	

25.	When you wore sunscreen, what number sunscreen or SPF (sun protection factor) did you use?

❍ Less than 15	 ❍ 15-29	 ❍ 30 or higher	 ❍ I don’t know

26.	How many times did you get sunburned last summer?

❍ None	 ❍ One or two	 ❍ Three or more

27. If you got a sunburn last summer, how many of the sunburns were painful?

❍ None	 ❍ One or two	 ❍ Three or more	 ❍ I did not get sunburned

28.	When you are outside in the sun, will you try to play in the shade instead of in the sun?	

❍ Yes	 ❍ Most likely	 ❍ Probably not	 ❍ No

29.	Will you put sunscreen on when you go out in the sun this summer?

❍ Yes	 ❍ Most likely	 ❍ Probably not	 ❍ No

30.	Does your school announce the UV Index?	 Yes No

31.	Have you had a school lesson before on sun protection?	 Yes No