Nebraska Youth Screen - Youth Version
As a juvenile cited by law enforcement, the Otoe County Attorney's Office would like certain information from you and a parent/guardian before proceeding with any criminal or juvenile court prosecution or diversion. You will be asked questions from the Nebraska Youth Screen to aid in the processing of this matter. A separate survey link must be completed by a parent/guardian. Please complete w/in 1 week of receiving your citation. If you are having difficulty with the survey please contact (402) 969-0319 or email
First & Last Name: *
Your answer
Gender: *
Race/Ethnicity: *
Phone: *
Your answer
Age at time of offense: *
Offense you were cited for (if more than one, select the top listed offense from your citation): *
What month were you cited? *
Have you received any other offenses prior to this incident? *
Please list prior offenses and dates if known (or indicate None). *
Your answer
Have you received any diversion or probation services in the past, in any county? *
With whom do you live? *
How many live in your household? *
Please describe your relationship with the parent(s) or guardian(s) you are living with currently: *
Your answer
What discipline/consequences at home have already taken place due to this incident? *
Your answer
Are your parents/guardian(s) employed? *
Are your parents/guardian(s) typically home evenings and weekends? *
Tell me your thoughts on school and completion of your education. *
Your answer
School you attend: please list *
Grade Level: *
Typical grades: *
Have you ever been suspended from school? *
Have you ever skipped school? *
How many class periods have you missed in the last two weeks? *
How many days in the past two weeks have you been tardy from school? *
If you've skipped school, class periods or had several tardies please explain reasoning. If no time has been missed, indicate n/a: *
Your answer
Are you employed? *
How many hours per week do you work?
How many close friends would you say you have? (those you can confide in and most trust) *
# of friends with law violations or substance abuse behaviors *
# of friends with good grades or involved in positive activities *
Were you intoxicated at the time of your offense? *
Have you ever tried alcohol? *
Have you ever tried marijuana? *
Have you ever tried cigarettes, chewing tobacco or nicotine vape products? *
List any other substance you have tried? (cocaine, lsd, heroin, meth, etc.)
Your answer
At what age did you first try alcohol? *
At what age did you first try marijuana? *
At what age did you first try cigarettes or nicotine vape products? *
How often do you or did you consume alcohol? *
How often do you or did you use marijuana? *
How often do you or did you use cigarettes or vape products? *
Have alcohol and/or drugs impacted your life in a negative way? Please explain or indicate "no". *
Your answer
Are you involved in any extracurricular activities (sports, clubs, boy/girls scouts, swim team, etc.) *
Please list the activities you are in throughout the year or indicate "none". *
Your answer
List 3 activities/hobbies that are of most interest to you. (things you do in your free time) *
Your answer
Have you ever been in a physical fight? *
Please explain: *
Your answer
How often do you get angry? *
In what ways do you show your anger? What types of things make you most angry?
Your answer
Have you completed any type of community service or volunteered in the past? *
List any volunteer experiences. *
Your answer
Overall, how do you feel about the offense you've been cited for? *
Your answer
Is there any additional information you would like to provide?
Your answer
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